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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ' SERVICE REQUEST# <br /> 1< 00 <br /> OWNER/OPERATOR `p 1 1 e eyl&A CHECK If BILLING ADDRESS <br /> rqzpl <br /> TFACILITY NAME - e .JO �' u, v Y <br /> SITE ADDRESS Ll 2'1 i„J�/I41"1 �^e _ <br /> Street Number Direction V" ,PJ Street Name /a_ v CGGI Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) /71 zr1 �L„ <br /> " ,Street Number lro—v.Stre¢t Name J <br /> CITY i\/A e, STATE � ZIP <br /> PHONE#1 �'J ('V EM. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <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 I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE d FEDERAL laws. <br /> APPLICANT'SSIGNATUREX DATE: j` ZZ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY 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 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. ,�,, Q,� I P y. <br /> TYPE OF SERVICE REQUESTED: CA V l/1(lrl.{. `C <br /> COMMENTS: D8/t <br /> 11 ?0 <br /> yRQtpN� ?� <br /> B9Cty�ep 6NT' <br /> ��ENT <br /> ACCEPTED BY: A-1 EMPLOYEE#: DATE: <br /> ASSIGNEDTO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ' PIE: <br /> Fee Amount: Amount Paid OD Payment Date 12M12-.2 <br /> - <br /> Payment Type �j„� Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />