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SAN JOAQUIWOUNTY ENVIRONMENTAL HEALTAPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property A Iv/-/Ylfj� FACILITY ID# SERVICE REQUEST# <br /> 7/0' dC <br /> I L4 <br /> OWNER/OPERATOR _ — <br /> A CHECK I(BILLING ADDRE55E] <br /> FACILITY NAME <br /> Z- <br /> IwoADDRESS N� C /l/o 1� �/ <br /> [�� Street umber - Direction Met Name <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> o A U /V G Street Number Street Name <br /> CITYf �TATE ZIP ?� J 7� <br /> PHONE#1 /r/ EXr• APN# LAND USE APPLICATION <br /> ( l - 639 <br /> PHONE#2 A En. BOS DISTRICT LOCATION CODE <br /> 1 � 1 ! <br /> 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> l 1 <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 /> S7 <br /> APPLICANT'S SIGNATURE: I/ DATE: <br /> PROPERTY/BUSINESS OWNERS OPERATOR/MANAGER ❑ OTnER AUTHORIZED AGENT <br /> IfAPPLLCANT is not the BTLLLNGPARTY 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 IS;ittle time it is <br /> provided to me or my representative. t� -,/�/1./� <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: �`�/ <br /> IV <br /> 41 ll'- <br /> MFNT <br /> ACCEPTED BY. - p , EMPLOYEE M DATE: ) <br /> ASSIGNED TO: I I •'✓A EMPLOYEE M DATE: <br /> Date Service Completed) (if already completed): SERVICE CODE: 0 P! <br /> Fee Amount le Z Amount Paid � .O� Payment Date 13 /3 <br /> Payment Type ( Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />