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SAN JOAQULv COUNTY ENVIRONMENTAL HEALTf. .IEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Sf2 L <br /> WNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> A't.ILITY NAME <br /> Y) P; <br /> ITE ADDRESS <br /> l [Street Number Direction Street Name i Cit Zi Cade <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Z � —/Q Street Number L� /v Stre amen <br /> TO l\I} C-STAT ZIP �y 2- 06'lr C f <br /> PHONE#t EXT• APN# LAND USE APPLICATION# <br /> (� Z-- 1R � JlJzb <br /> PHONE 2 EXT. BOS DISTRICT LOCATION CODE <br /> sc -W cc I 0"�5 i t/� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared thi pplication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stan ds,STATE and FEDERAL laws. / <br /> APPLICANT'S SIGNATU E: ( Y to W t y�Q��4' Cep <—� �_ ATE: U I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/NIANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLiNGRgTy,,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 DEPARTNfENT as soon as it is available and at the same time it is <br /> provided to me or my representative. pffilmml <br /> TYPE OF SERVICE REQUESTED: For GLL 5Ct k (U <br /> COMMENTS: <br /> MAYO 6 �i/, <br /> SAN JOAQUIN ICotlNtY <br /> ENVIROMENTAL <br /> HEALTH DEPA/RTi1 tNir <br /> ACCEPTED BY: I EMPLOYEE#: DATE: <br /> ASSIGNED TO: lt1 Z EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: U / P/E: <br /> Fee Amount: 12 > (2-) Amount Paid I2S OCA Payment Date <br /> Payment Type Invoice# Check# 2-P 3:�> Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />