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SAN JOAQU :OUNTY ENVIRONMENTAL HEALTF ;PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Re-6 1 '1'-n5ns�n 6(:4 FFO 000 FESSJ 5e0oLf$30 <br /> 07R/OPEWOR ❑ <br /> S I Q4r3 I�U m O r CHECK If BILLING ADDRESS <br /> FACILITY NAME us Iq <br /> Ems_ ed ra h <br /> SITE AD s / .e4--"e rnQ n �7 y" <br /> Street Number Direction StreetNam�nC � city Zip Code <br /> HOME or AILING ADDRESS (If Different from Site Address) <br /> •aStreet Number Street Name <br /> CITY SAT �cip/� <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (SCS) 1 -4a 05-- r no <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTO I CHECK if BILLING ADDRESS <br /> BUSINESS NAME � �l !e—U m �r PHo - E <br /> HOME or MAILING ADDRESS FAX# <br /> oS nckci ane b Jd. ( ) 5&- C)4g9 <br /> CITY A f \t r r l f STATE c� ZIP 3 3� <br /> BILLING ACKNO EDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> ackro ;ledge that alt site and/or project specific EiJVIRONIMENTAL 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,Standar ,, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: q S DATE: 9 b <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 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. __ II f, <br /> TYPE OF SERVICE REQUESTED: e l/n��c_c_� i le I bC sRs` A <br /> COMMENTS: _ <br /> C;�� fit, <br /> ACCEPTED Elt: <br /> EMPLOYEE M tl DATE: <br /> ASSIGNED TO: G- EMPLOYEE M qts DATE: <br /> n <br /> Date Service Completed (if a ady completed): SERVICE CODE: t g PIE: <br /> Fee Amount: ?—F5Amount Paid C Payment Date ( Z <br /> Payment Type t/ Invoice# Check# 3 2 t Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />