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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> '�-- N Q,0 Q 'tg S CO <br /> OWNER(OPERATOR _���/�/n CHECK If BILLING ADDRESS <br /> FACILITY NAME /V/J `p <br /> SITE ADgJ2ESS �f,`/v <br /> -� Str) umber Direction �' �' " Street Name �� Cit ZI Code <br /> HOME or ING ADDRE//Sff(if <br /> Different from Si Adaness) <br /> � L'LV / Street Number Street Name <br /> CITY P-a6e LA STAT,- � ✓-/� <br /> PH E#i EXT• APN# LAND USE APPLICATION# <br /> (�� <br /> PHONE#Z EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> \'•�� n/ (� �/ /CHECK If BILLINGJAyD(DRESS <br /> BUSINESS NAME � C LI�J//V� (R ) L���' �/v xr. <br /> HOM�� C FAx#� ) <br /> CITY F-7 /) STAGE 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 /> APPLICANT'S SIGNATURE: DATE: <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/kite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at thi it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: q� <br /> COMMENTS: p���MOgQU/ C�®�J <br /> FI„�4��IR��I� 1C 0rVl11TI' <br /> �EP�M HT <br /> ACCEPTED BY: EMPLOYEE#: DATE: �\2� <br /> ASSIGNED TO: - \ck EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: Wo <br /> Fee Amount: — Amount Paid �S to �/ Payment Date V L <br /> Payment Type �� Invoice# Check# Received By: / <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />