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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER i OPERATOR <br /> f��tnJtD CHECK If BILLING ADDRESSO <br /> FACILITY NAME <br /> SITE ADDRESS �(J A I CU�� �;a S} J T K� <br /> Street Numoer Direction Street Name Cit a �oae <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1ZSC51 ` <br /> N f� ' <br /> Street Num I., l Street Name <br /> CITY STATE ZIP <br /> S <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (taI ) 5c1 _ r5w <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ` 1 5� <br /> N L. l V- vJ CHECK if BILLING ADDRESS <br /> BUSINESS NAME , ry�i S t /1 t) _a� Q P E# EXT. <br /> Z� <br /> HOME Or MAILING ADDRESS /7� �I /� /� FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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, TATE and FEDERAL aws. 1 <br /> APPLICANT'S SIGNATURE: ��^ DATE: ( Cz <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MA AGER EJ 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 and at the same time it is <br /> provided to me or my representative. JOA <br /> TYPE OF SERVICE REQUESTED: LA t'( 1—)-b t <br /> COMMENTS: `I <br /> S SEp <br /> y�T IN co <br /> y�F� �N�Y <br /> ACCEPTED BY: ul EMPLOYEE#: DATE: <br /> ASSIGNED TO: L EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 0 P 1 E: p <br /> Fee Amount: S Z Amount Pa' 6;� opPayment Date <br /> Payment Typej Invoice# Check# Rece lved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />