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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of&useless or Property FACILITY ID# SERVICE REQUEST# <br /> rCLAe,a <br /> OVAER/OPERATOR CHECK if BILLING ADDRESS <br /> 2 Z <br /> F Llrr <br /> SITE ADDRESS <br /> ]j <br /> I O l.V Street Number Direction L—� h l!-�lJ SL-Ci1l Nom' 1 1 t�JcCRY <br /> .•` "l ZI C`,iode <br /> HOME or MAILING ADDRESS (if Different from SP Add ) ' ,m p-ed e <br /> Street Number Street 1 <br /> Crtr <br /> PHONE#1 EiT- APN# LAND USE APPLICATION# <br /> (ZC?'f ) la(o <br /> PHONE#2 Ex . BOB DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> RECIUESTOR <br /> CHECK N BIW NG ADDRESS <br /> BUSINESS NAME PHONE# E"T <br /> HOME or MAILING ADDRESS FAX# <br /> CHY 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 ENvIRONMENI'AL 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 I have prepared this application and that the work to be performed will be done in accordance with all SAN JoAQu[N <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws,, <br /> APPLICANT'S SIGNATURE: DATE: S <br /> PROPERTY/BUSINESS OWNER OPERATOR/MAMA 'O OTHER AUTHORIZED AGENT <br /> I,JfAPPLICAAT is not theBffjffGPAnTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I,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 COuNrY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQDESrED: Q ,B �I` t PAYMENT <br /> COMWAM: NECEIVED <br /> ;UG 0 2 202 <br /> SAN JOAQUIN COUNTY <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: t�1/''/�� 6 EMPLOYEE#: DATE g-J �l <br /> ASSIGNED TO: �' (I� EMPLOYEE M DATE�/JjS <br /> Date Service Completed (if already completed): SERVICE CODE: srZ� o PIE: <br /> Fee Amount: 40k Amount Paid /� Payment Date B 3 Z Z <br /> Payment Type c4iqckInvoice# Check# /00 / Received By: <br /> EHD 48-02-025 FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />