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SAN JOAQUI *LINTY ENVIRONMENTAL HEALTH#PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR q <br /> RG: 1"G'f/'G+1>' CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS��� �,�.� ���,.. �{ Sj o` 'c;Y� cl�a� 7 <br /> g6 C' Street Number Direction Street Name Citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) ,h <br /> `J lStreet Number ` Street Name <br /> CITYh CS ZIP <br /> _T <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (4/4) �-�3 �T/.7Z-:' <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQ U STOR CHECK If BILLING ADDRESS❑ <br /> �/ ' / l Com. <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 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,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE:�May -` DATE: 7 7- <br /> PROPERTY/BUSINESS OWNER Ej OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT 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 environmentaUsite assessment <br /> information to the SAN JOAQUIN COUN'T'Y 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: Usr (fU 21106,/ PA E�`�EQ <br /> COMMENTS: <br /> V / sy, <br /> 1J1� <br /> ( SP ENV�a�NPPRTMEN <br /> H��1N pS <br /> ACCEPTED BY: EMPLOYEE#: 2� DATE: <br /> 1-7 <br /> ASSIGNED TO: EMPLOYEE#: /- DATE: <br /> Date Service Completed (if already completed): SERVIC CODE: I P1 E:7 7 <br /> Fee Amount: ^ Amount Paid Payment Date v <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />