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SAN JOAQUIN " ')UNTY ENVIRONMENTAL HEALTH"-PARTMENT <br /> SERVICE REQUEST <br /> r Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME A �C� ^ t a /�� ���/ 1„•,ry OS��_\ <br /> SITE ADDRESS l �Q S 1 ,�it.. � A� --- <br /> St-t> <br /> l�►�. <br /> Street Number Direction V�J Street Name Ci ` Zi Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) C� -rE� �O l T .lVl�lV <br /> Street Number Street Name <br /> CITY �Ao t tit A STATE �� ZIP I oco Z-:�> <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT7-7[LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> I0`A��� S�vf►+'Y���� CHECK if BILLING ADDRES <br /> BUSINESS NAME >�sSOL!���--�rPHONE# EXT. <br /> 1(D CoCo i$Z� <br /> HOME or MAILING ADDRESS FAX# <br /> Z4-44- <br /> CITY STATE ZIP -7 4- <br /> BILLING <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project speck 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 /> APPLICANT'S SIGNATURE: (� DATE: �� ��►yZ�1 C7C. <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT t�IZpJ�CY �r�l���C <br /> IfAPPLicANT 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 proporty located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmefo{si�t ��,assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the sa>6hime it is <br /> provided to me or my representative. MAY <br /> TYPE OF SERVICE REQUESTED: SJO 6 <br /> AN <br /> COMMENTS: HEALT,IR�ONMJENTAtNIY <br /> il�V lJiV� C�Qp, C`C,IC C1S'�l 'a VL�e02 'rWNT <br /> �1zr»bU�--t tit r�•es , T�e�tov e� �x�s-rt iJ� '� '-'�Pp� �i�o I n�-ez�.1 t <br /> A0r31�> vtZ>c $ . ���'ln�G� -C�iN�.S 710 P-4S tAJKD <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ,g P I E <br /> Fee Amount: Amount Paid l O O Paymen Date s I <br /> Payment Type `� Invoice# Check# 1 S 2— Received By: <br /> E H D 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />