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r p- l J v'M'IN' <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMI♦;NT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> e--J F V �-- I Q.cb��� ss� <br /> OWNER/ OPERATOR CHECK If BILLING ADDRESS <br /> FACILITY NAME r"' I <br /> SITE ADDRESS W <br /> � <br /> SlroatNumber Dlrectlon ' � StreetName 1 'Oelt ZID Code <br /> HOMEor MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT, APN # LAND USE APPLICATION # <br /> PHONE#2 EXT. SOS DISTRICT LOCATION COOS <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS© <br /> Bu 1N ss NA PH.QNE t 1 L? _ <br /> t eA <br /> HOME or MAILIN ADD S I FAX# <br /> CITY R4) s STATE (1-4 zip cis a k_ <br /> BILLING AC)KNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL IIEALTH DEPARTMFNr 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, 5landard IT at FED AL 1 <br /> APPLICANT'S. SIGNATURE: DAT] <br /> PROPL<',RTYI BUSINESS OWNER❑ OPERATOR IMANAGER ❑ OTHER AUTnoiuzBD AGENT <br /> � <br /> IfAPPLlCAN'L'is not th e B mrLmG PAR Ty, pro of 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 L'NVIRONME.ITAr, HEALTH DEPARTMENT as soon as it is available and a �q 5ie time it is <br /> provided to me or my representative. A r,lL/Il� <br /> TYPE OF SERVICE REQUESTED: <br /> titt <br /> COMMENTS: SAN <br /> EC 2 12023 <br /> HE /RONMENTUNTy <br /> EPA R TMENT <br /> ACCEPTED BY: / ( EMPLOYEE#: ( DATE: f z <br /> ASSIGNED TO: EMPLOYEE#: DATE: , Z <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: .J Amount Paid Payment Date <br /> Payment Type Invoice # Check# 173 Lk,6 2-.-S Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11/17/2003 <br />