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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> TMA-`512 ar5+U'rcm-f— �� C� <br /> U.I I ��S� <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS E] <br /> &FACILITY NAME <br /> SITE ADDRESSacru <br /> Street Number Direction Street Name(� Cit Zi Code`p <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 1O p 1/� U <br /> Street Number �� Y/l� �Street 1NNam <br /> CITY Q STATE ZIP <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> (C�zs) 1.S 3 -OL(O (OR <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ^ CHECK If BILLING ADDRESS <br /> BUSINESS NAME � V l ^-�� � PHONE# <br /> — EXT. <br /> \ CC. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY1 cue-C) STATE C ZIP Q r <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 FEDERA laws. <br /> APPLICANT'S SIGNATURE: DATE: �/� - /�-�� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 1@ CEO <br /> O <br /> If APPLICANT is not the BILLLVG 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. <br /> TYPE OF SERVICE REQUESTED: L r. t E <br /> COMMENTS: <br /> 0C 3 0 202 <br /> SAN JOAQUIN COU Ty <br /> ENVIRONMENTAL <br /> HEALTH DEPARTIVEpIT <br /> ACCEPTED BY: - /Z vL i EMPLOYEE#: �� 3 DATE: I v� 3v 11 <br /> �3 <br /> ASSIGNED TO: vv EMPLOYEE#: -� 0 3 DATE: l <br /> Date Service Complet (If already completed): SERVICE CODE: ` E: <br /> Fee Amount: Amount Paid Payment Date / 6 ? b 2 L� <br /> Payment Type ` Invoice# Check# 1 — b Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />