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v' SAN JOAQUIN `"OUNTY ENVIRONMENTAL HEALTHX�EPARTMENT <br /> Aftw SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> FType Business or Property <br /> 5 JVDR I OPERATOR CHECK if BILLING ADDRESS <br /> FACILrrY NAME f <br /> SITE ADDRES 1 �C� [ y PC �� 3 <br /> Street Number Direction <br /> Name Ci ZiCade <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> STATE ZIP <br /> CITY i:J <br /> PNONE#1 EXT. APN# LAND USE APPLICATION# <br /> o0q 1 Z <br /> T �FOCON CODEPHONEI EXT BOS DISTRIC <br /> CONTRACTOR f SERVICE REQUESTOR <br /> REQU STOR � CHECK if BILLING ADDRESS© <br /> BUSINESS NA PNONE# o EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> fn 1 . (&S I `7`7 ff` 3 // <br /> CITY . P R"—` STATE IrTf ZIP t{�"� fL <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,lopera \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,Standa ,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: D <br /> PROPERTY/]RUSTNESS OWNER❑ I' TOR/MANAGER ❑ OTHER AUTnowzED AGENT[ <br /> If APPLICANT is not the B/LLING PARTY,proof of authorization to sign is require rt c 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. <br /> TYPE OF SERVICE REQUESTED: f -n o i-) r`s GC L C lL I� 01�ID <br /> COMMENTS: <br /> z s t A-c�,g-'i-7 <br /> Opoll-�N�p6 <br /> ACCEPTED BY: C C EMPLOYEE#: )2, 2_1 DATE: J G <br /> ASSIGNED Ta: ~� EMPLOYEE#: �'1 �v DATE: <br /> i 1) (o <br /> Date Service Completed (if already completed): SERVICE CODE: 01E: f �� <br /> Fee Amount: (,= Amount Paid Ell. v Payment Date 31.310- <br /> Payment Type Invoice# Check# !r C� Received By: • <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />