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0 <br /> SAN JOAQ1OCOUNTY ENVIRONMENTAL HEALT EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> 01 }� <br /> SITE ADDRESS N <br /> I(PJ Street Number Direction V " l >1�6&Name � t Zip Code <br /> HOME Or MAILING ADDRES (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( ) -Ila 2390 D - -oSa - ?�j <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) 6C . <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> Pock' Q- 'mem Ctvi f <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADDRESS ' <br /> FAX# <br /> �d00 )'l0-fS/NZ k (del ) s 7 '&,r5;; <br /> CITY ce v es I <br /> STATEC /I ZIP 9 <br /> S3&';7 <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 TAT nd FEDERAL la S. (� <br /> APPLICANT'S SIGNATURE: .�4' DATE: U/B/ �3 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLiCANT is not the BiLLINGPARTY,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 same time it is <br /> provided to me or my representative. 4 <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 14 t7 Q [ <br /> SA/V'/0,4Q <br /> lj <br /> /pgQlj <br /> lfv <br /> Ari,p044k1V NAY <br /> AgTM <br /> T <br /> ACCEPTED BY: ��� EMPLOYEE#: t'7 v DATE: /-3 <br /> ASSIGNED TO: `C EMPLOYEE#: lo q Lf <br /> DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Z-Z- P/E: c O Z <br /> Fee Amount: Z Amount Pai �ZSb.Co Payment Date <br /> Payment Type Ji Invoice# Check# I� Received By: 'L <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />