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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />CHECK If BILLING ADDRESS <br />SERVICE REQUEST # <br />oc� <br />BUSINESS NAME <br />S�mCL�Co� �3 <br />OWNER OPERATOR <br />CHECK If <br />HOME/Or MAILING ADDRESS �j <br />BILLING ADDRESS <br />FACILITY NAME \ <br />SITE ADDRESS <br />ek <br />STATE �i^ <br />ZIP <br />Street umber <br />Direction <br />Street Name <br />city <br />Zia Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />ST,9TE ZIP <br />PHONE #"1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />(`oA) —L S 3� <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR— <br />CHECK If BILLING ADDRESS <br />'1--) <br />BUSINESS NAME <br />PHONE # <br />�'l <br />EXT. <br />C �-C_S <br />HOME/Or MAILING ADDRESS �j <br />FAX# <br />CITY / ✓� C <br />STATE �i^ <br />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: y DATE: <br />PROPERTY/ BUSINESS OWNER 13 OPERATOR / MANAGFan 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/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available PAsame time it is <br />provided to me or my representative. AL-.fth- <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />U ?n?3 <br />�QRpUtN COON <br />cryo pMNry <br />ACCEPTED BY: 661 yu Cy- 0 EMPLOYEE #: DATE: L O .23 <br />ASSIGNED TO: EMPLOYEE #:9Z <br />DATE: G <br />it,Date Service Completed (if already completed): SERVICE CODE: OLI P / E: H 1 <br />03 <br />Fee Amount: of I Amount Paid ���� Payment Date 2d 2 3 <br />Payment Type C Invoice # Check # Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />