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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> FA 0 C0 ": !)q :EI) � S \zOmc (6c1 <br /> OWNER OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> L / v %/7 r161171I -L L .>h'.gexz T"ii2 <br /> SITE ADDRESS `" >C x` <br /> 6 z Street Number Direction cb � � Street N/H Ile ame <br /> ��� x �" Cit � odtf <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> o212 � <br /> F" J / L Street Number Street Name <br /> � . C & /ITY //�, / 'JZ n _ STATE R ZIP <br /> PHONE #1 Y' ✓� Ex-r. APN # LAND USE APPLICATION # <br /> LU 3 - � S <br /> PHONE #2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> y REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS �NAME /, / ( PHONE # 7 EXT. <br /> x HOME or MAILING ADDRESS FAX # <br /> X CITY L /(� T E % 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 and FEDERAL laws . <br /> X APPLICANT ' S SIGNATURE : DATE . <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT �� r z <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is requir;d 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 t0 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 . p <br /> TYPE OF SERVICE REQUESTED : t S RECEIVED <br /> COMMENTS : <br /> 14 1023 <br /> SAN JOAQUIry N U�, <br /> ENVIRON <br /> EALTIi pAL <br /> EpARTMENT <br /> ACCEPTED BY : SC / (� \ � n �) EMPLOYEE M DATE : .211 y <br /> ASSIGNED TO : /y vD( / / ` v��// -���� EMPLOYEE M DATE : oL / / / 3 <br /> Date Service Completed ( if already completed) : SERVICE CODE : f _2qf P I E:7,, S <br /> Fee Amount : �` Amount Paid Payment Date / ` 2� <br /> Payment Type Invoice # Check # 5 9 Received By : <br /> EHD 4&02-025 SR FORM (Golden Rod ) <br /> REVISED 11 / 17/2003 <br />