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SAN JOAQUIN"'OUNTY ENVIRONMENTAL HEALTF DEPARTMENT <br /> SERVICE REQUEST <br /> T e of Bus ns"orProperty FACILITY ID# SERVICE REQUEST# <br /> (YAER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME t <br /> t)SITE , Street Number irection �•� Street Name Zi Code <br /> HOME OrM ING ADDRESS (If Different from Site Ad ess) ` <br /> Street Number �IR76/1)'/Y4&reet Name � <br /> CITY N' STA E ZIP <br /> PHONE �� EXT. APN# LAND USE APPLICATION# <br /> 19) -3/-�) X, <br /> P #2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR , <br /> 6 CHECK If BILLING ADDRESS � <br /> BUSINESS NAME i �j,� PHONE#793 <br /> EXT. <br /> HOME OrMAILI ADDR�S-�� j /� / ('�# ) <br /> /'Jl h lV <br /> c, <br /> CITY i1TE ZIP�;,j <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 a plication and that the work to be performed will be done in accordance wi h all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar TATE and FE ERA laws. <br /> APPLICANT'S SIGNATURE: U 'v DAT�&(� <br /> ry e <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER El 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 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. (PAYMENT <br /> RECEIVE D <br /> TYPE OF SERVICE REQUESTED: Li ST— 'F( / <br /> COMMENTS: MAR 9 2004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: [�I EMPLOYEE#: 03 Z DATE: > q <br /> ASSIGNED TO: L EMPLOYEE#: 3 5 fir ; DATE: '3 G} <br /> Date Service Completed (if already completed): SERVICE CODE:" r Ct 1 E: <br /> Fee Amount: T22 2- Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />