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SAN JOAQUIN NTY ENVIRONMENTAL HEALTH PARTAIENT <br /> SERVICE REQUEST <br /> FACILITY iD# SERVICE REQUEST# <br /> Type of Business or Property. �� <br /> dna_ <br /> OWNER/ OPERATOR CHECK If BILLING ADDRESSLJ <br /> ,AA. 1 0 c a <br /> FACILITY NA�0��i Vi Duks <br /> _ <br /> SITE ADD RESS cl 5 3Y 0 <br /> t <br /> 43 reef Number Direction <br /> Street Name Git Zi Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> 9,3G} A (� Street Number Street Name <br /> CITY cN STA E ZIP <br /> cironf C ta CI q sem, <br /> PHONE#i LAND USE APPLICATION# <br /> EXT. rr4� <br /> 3b5 0� C3 �1�� -zy <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE, REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> PHONE# Exr. <br /> BUSINESS NAME <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 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 application and that the work to be peeUTHORIZEDAGENT <br /> one in accordance with all SAN JOAQU[N <br /> COUNTY Ordinance Codes,Standards,.STATE and FEDERAL laws. I <br /> APPLICANT'S SIGNATURE: ell) ATE: ! r a <br /> PROPERTY I BUSINESS OWNER❑ OPERATU NZANAGER OTHER ❑ <br /> I APPLICANT is not the BILLING PARTY proof of authorization to sign is required q f N( <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the pro 91V the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentall//ssit s �t <br /> information to the SAN 3OAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and antsa e7time it is <br /> provided to me or my representative. �yW�DO <br /> r TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> We w tce, J Us•T �t c�� Nu i tZt<-r�O�Fit-• 5�i�►t� µi.x- S�}M TD <br /> QvnVt� r j w�� moc W r (w W PrIOL -tr -Wb FfU DUB` ODUti-r IIT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: 3 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ;2-- P 1 E: <br /> 4. <br /> Fee Amount: CAO Amount Paid f�31s: C7 o Payment Date <br /> Payment Type �S� Invoice# Check# Receiived By: <br /> EHD 48-02-025SR FORM(Golden-Rod) t <br /> REVISED 11/17/2003 <br />