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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> � 3 <br /> OWNER/OPERATOR� <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS CA �cQ L TL R,t.hr� C�1- ys3 <br /> Street Number I Direction Street Name CI 1 Zip Code <br /> HOME Or MAILING ADDRESS (If Different fromSiteAddress) <br /> O a VL !�" Street Number Street Name <br /> CITY .i- STATE ZIP <br /> GA R <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (q2,-) 7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK H BILLING ADDRESS <br /> BUSINESS NAME ` ,I e PHONE# Eu <br /> t cry <br /> HOME or MAILING ADDRESS FAX# <br /> ( Z ( ) <br /> CITY �L1 ..� STATE L� ZIP <br /> BILLING ACKNOWL DGEMENT: 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, S ATE and FEDERAL laws. 1 <br /> APPLICANT'S SIGNATURE: �� DATE: I <br /> PROPERTY/BUSINESS OWNER❑ OPE TOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IJAPPLxANT is not the BILLING PARTY proof of authorization to sign is required Tule <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 ae 'nentalusite assessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it i5 avai !rme time it is <br /> provided to me or my representative, CJe <br /> TYPE OF SERVICE REQUESTED: AN <br /> COMMENTS: SA&J,, <br /> Ht�n QUI E OUN� <br /> HDEPAR M Nr <br /> Tlao WeCk - ///��� <br /> ACCEPTED BY: EMPLOYEE#: q O DATE: <br /> ASSIGNED TO: 4�/I n,�l O L . EMPLOYEE#: 5 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 52 3 P/E' I69 DI <br /> Fee Amount: Igz S�'U Amount Pa' SCO �b Payment Date )�?� <br /> Payment Type Invoice Invoice# Check# 13'753���� Received By: <br /> EHD 48-02-025 7 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 n /I J7 � K" I `�7 <br />