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SAN JOAQL._ 20UNTY ENVIRONMENTAL HEALTh — ,,PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> f2roo 6 <br /> OWNER/OPERATOR <br /> — CHECK If BILLING ADDRESS <br /> S Olt c) <br /> FACILITY NAME <br /> SITE ADDRESS <br /> L� cjS�� <br /> Street Number Direction Street Name <br /> CityZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> 90 ) Cir a <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> n CHECK if BILLING ADDRESS <br /> BUSINESS NAME I \ PHONE# EXT. <br /> 4L)Y1i;S--7/13 <br /> HOME or MAILING ADDRESS FAX# <br /> 4 L)�-) �)/ S -�c J 3 <br /> CITY STATE -1 ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 1 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: 1�4--�J-�S DATE: <br /> / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tide <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 an <br /> provided to me or my representative. <br /> PA <br /> TYPE OF SERVICE REQUESTED: ugr RECE� T <br /> COMMENTS: JAN <br /> 44 c <br /> SAN ROQIJ/N(�"�'rp"""UIN�EI�1 HEAL T <br /> EAL7}f pEpMm� ,gLFV /J��'��I�tS <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: r P I E: <br /> Fee Amount: 0 -T <br /> Amount Paid 1 S Payment Date <br /> Payment Type ✓ Invoice# Check# -7 Received By: �(�- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />