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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> )`YS�-Gv(A.,%+ -)5ACC) 12J <br /> OWNER/OPERATOR <br /> 9-u-" - CHECK if BILLING ADDRESS <br /> F-9-u-" <br /> Y1 C- <br /> FACILITY NAME 1` J� <br /> SITE ADDRESS I `,7 q l r�.�e� Sc�c r a,n c„�}c} '1�C y S SD <br /> ���17: <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ems• APN# LAND USE APPLICATION# <br /> (91(a ) q1Q <br /> PHONE#Z Ex-r. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR M CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY W 00 I I 1 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 ide rm. <br /> I also certify that I have prepared this a ' ation and that the rk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar , STATE and FEDE aws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER® PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICI NT 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 tk Sarne time it is <br /> provided to me or my representative. '67AY <br /> TYPE OF SERVICE REQUESTED: �anS�l�c��i t.� iylt�Qel <br /> COMMENTS: <br /> R ?8 <br /> ?�gqN d0AQUIIV C23 <br /> ATN7yH' LHp � <br /> EpqNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: Z� EMPLOYEE#: DATE: <br /> Date Service Compl ed (if already completed): SERVICE CODE: P/E: (1 0 Z <br /> Fee Amount: S(a"— Amount Paid Payment Date 2 c 2--s <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />