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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> onn� -7G I <br /> OWNER/OPERATOR I0I A Am / ' k) I <br /> 0 le CHECK if BILLING ADDRESS <br /> FACILITY NAME J p n Jn <br /> . <br /> SITE ADDRESS <br /> Simi Number Dirvction Street Name C' Zi Code <br /> HOME Of ILI�G ADD 5$,(1{D�fferen f\I Slte Address) <br /> pt GJG y {- Street Number Street Name <br /> CRY $TATE q4606 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (5[D) 4'12 -5343 <br /> PHONE#2 Ext, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# En. <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standamp-mok,) <br /> TATEpd FEDERAL laws. I (� <br /> APPLICANT'S SIGNATURE: &a1_ DATE: Q V —lp �/�22,1 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AtrmoRIzED AGENT 13 <br /> Jf APPLICANT is Not the BILLING PARTY Proof a,f authorization to Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the sfPAYWNT <br /> provided to me or my representative. ,, \\ '/ a D <br /> V <br /> TYPE OF SERVICE REQUESTED: 6 D D 1 1-0 CX I t Nt <br /> COMMENTS: 22 <br /> SAN JOAQUIN C LINTY <br /> ENVIRONIWEP AL <br /> HEALTH DEPAR ENT <br /> ACCEPTED BY: b/ i EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE III: DATE: ` C( <br /> Date Service Co plated (if a dy completed): SERVICE CODE: 149 P/E: 0 <br /> Fee Amount: Amount Paid Payment Date 7j L Z <br /> Payment Type V Invoice# C>&# C Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />