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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> i - F A UA 53 59-W BI V:qq <br /> OWNEF�OPERATOR <br /> ' / { D CHECK If BILLING ADDRESS <br /> FACILITY NAME C <br /> SITE(ADDRESS f JJ��, �/,Ln/ <br /> & � Street Number Direction O�`Street Name Cit <br /> HOMEOr MAILING ADDRESS (If Different from Site Address) hl�3 r ©/,-1to� 5 <br /> StreetJNumber (/ Street Name <br /> CITY , STATE IP, <br /> PHONE 1 EXT. APN# LAND USE APPLICATION# <br /> cy ) 82✓ 3 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR "�o )�� <br /> n c J C CHECK If BILLING ADDRESS <br /> BUSINESS NAME l� PHON ExT.e� �3 2 <br /> HOME Or MAILING ADDRESS62� F— 0� si ( # ) <br /> CITY 1_0d ° STATE ZIP 5�LLM <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 fon-n. <br /> I also certify that I have prepared this applicati d that t e work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Slandar s, T and F E laws. (y <br /> APPLICANT'S SIGNATUR <br /> E: - DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANthe 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 Iie time it is <br /> provided to me or my representative. Fr <br /> TYPE OF SERVICE REQUESTED: ViED <br /> COMMENTS: 8 2413 <br /> RONIN COUNT, <br /> HE4LTiy DEPART NT <br /> ILV)a U)oe'r hl <br /> ACCEPTED BY: I EMPLOYEE#: ZI DATE: <br /> ASSIGNED TO: EMPLOYEE#: /_ f DATE: I <br /> Date Service Co already completed): SERVICE CODE: P4: <br /> E: J (i <br /> Fee Amount t �p Amount Paid .-� Payment Date <br /> +CJ <br /> Payment Type Invoice# Check# Recei d B <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />