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V V <br /> SAN JOAQOCOUNTY ENVIRONMENTAL HEALTOEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C A-,+ �� �� C�tiat;� 2-C43 5,2C04�19/&4?U <br /> OWNER/OPERATOR <br /> � CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> V <br /> SITE ADDRESS � ; Zo . 3 $oZCJ-7 <br /> Street Number I Direction Street Name Cit Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 5a� l tom✓ �JCi,rL <br /> Street Number Street Name <br /> CITY C STATE Zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 'q DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLrcANT 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. j PA <br /> r N <br /> TYPE OF SERVICE REQUESTED: `�G> T (--//-er �L� J� "t F/vlEp <br /> COMMENTS: /� ✓ �S v �' l V)C�tJ �� r V S 4% Z813 <br /> H R0 UtM Co <br /> E4C�0 P�NTu� <br /> �FNT <br /> ACCEPTED BY: ac�b-e,-.4 V c Cle-l�vy--, EMPLOYEE#: 3°x`7 3 DATE: <br /> ASSIGNED TO: ` Y1� ��� EMPLOYEE M c,?C , `Q DATE: 1(5t <br /> Date Service Completed (if already completed): SERVICE CODE: C 61, ' FP/E-. <br /> Fee Amount: A 1615 Amount Paid has — Payment Date la /-7, 0 <br /> Payment Type / Invoice# Check# 6 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />