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SAN JOAQUVI%w JUNTY ENVIRONMENTAL HEALTH,../PARTMIENT <br /> SERVICE REQUEST <br /> Type of Business or Properly FACILITY ID# SERVICE REQUEST# <br /> -5iZo0 SI o ('00 <br /> OWNER 1PERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILRY MAKE Ue <br /> e e <br /> L i <br /> SITEADDRESS <br /> 2-go n Street Number pirectign } l3 Slree!Name �` Zip Code <br /> HOME of MAILING ADDRESS (If Different from Site Address) �U�� ��_I�� 3��� �f•{U(' <br /> `nC1Vl Street Number l:� t`re€t ame <br /> CITY 4 a��l�n STATE ZIP <br /> PH0NE#1 J ExT. APN# LAND USE APPLICATION# <br /> (qZ7 1 1 —d4 0 �7 <br /> - <br /> PHONE#I EXT, BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> R EQIl ES TOR CHECK if BILLING ADIDREM <br /> BUSINESS(NAME V PHO E# EXT. <br /> HOME or MAILING ADDRESS <br /> FAx# <br /> Awne (qi6 )-?66-863 ( <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDG ME[NT: 1, 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 JpAQUIN <br /> COUNTY Ordinance Codes,Standards,S and FE RA laws. !!// <br /> APPLICANT'S SIGNATURE: i DATE: —r p-6—7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER © OTHER AUTHORIZED AGENT "t /ate�- <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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at-hire same time it is <br /> provided to me or my representative. �j1E p <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> S�p GOVNC'{ <br /> �pPQUtjMrcN�M�� <br /> SA�NJ�RpD�pPR� <br /> VW <br /> ACCEPTED BY: EMPLOYEE DATE: <br /> ASSIGNED TO: EMPLOYEE#: �S� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: Q <br /> Fee Amount: Amount Paid j o2p O-E) Payment Date 7 O� <br /> Payment Type Invoice# Check# Received By: <br /> EHO 48-02-025 SIR FORM(Golden R� <br /> REVISED 11117/2403 <br />