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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> oSIWCC 17?oy— <br /> OWNER/OPERATORAiA <br /> CHECK If BILLING ADDRESS D <br /> FAciLrrY NAME <br /> SITE ADDRESS 1 % ! <br /> Street Number Direction �t Nam0(3041�c ZCode <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Nu Street Name <br /> CITY STATE zip <br /> PHONE#1 FXT• APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• SOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> y HECK if BILLING ADDRES <br /> DUSlNESS 111AM>< <br /> HOME or MAILING ADDRESS <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 or <br /> 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,St , TATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTtI A JTIIORIZED AGENT❑ W <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMA'T'ION: 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. US 7— 7-8D F f 7-- <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> REGENED <br /> JAN - 6 2411 <br /> SAN JaAONMFKTAI- <br /> ENVIRfT <br /> t{Ay7t- DEPAP E <br /> ACCEPTED BY: �j�1 Vit EMPLOYEEDATE: r b r <br /> ASSIGNED TO: 11 A r-- EMPLOYEE M tI } DATE: Y / f/ <br /> f`t ( 6 <br /> Date Service Completed (if already completed): SERVICE CODE: / P 1 E: 2?&9 <br /> Fee Amount: Amount Paid (p D Payment Date f <br /> Payment Type Invoice# Check# (� Received By: <br /> EHO 48-02-025 5R)dF7lv3(Golden Rod} <br /> REVISED 11/17/2003 <br />