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SAN JOAQSCOUNTY ENVIRONMENTAL HEALTOEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Oct X <br /> OWNER/OPERA R <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAMEn/ 5 eA r /I `I i i —Ro C <br /> SITE ADDRESSu ) P �/`^� C� �`Z <br /> J, CJ Street Number D�on tQ t e Name � ,� Cit �i Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) ' <br /> ( <br /> Street Number S re t Na e <br /> CITYr, STATE ZIP <br /> C' C d <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> (.coq) 2t�.r p <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) V`'� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> j <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 an FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: / --2,2-- <br /> PROPERTY/ <br /> -2,2—__PROPERTY/BUSINESS OWNER PERATOR/MANA OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLLVGPARTY 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 same4ime it is <br /> provided to me or my representative. Nq <br /> TYPE OF SERVICE REQUESTED: �Av� <br /> COMMENTS: N cot) 4 <br /> 40 <br /> 4Q 1 <br /> Fq<TyO�q NTq <br /> MF T <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: TP/E. CPI <br /> Fee Amount: <br /> U `? Amount Pali �C Payment Date <br /> Payment Type s Invoice# Check# Recei ed By:��A <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />