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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> T#jpe of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME A1 � <n _ 1 <br /> SITE ADDRESS E d 'v C� �� C I� Z© G <br /> Let Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1 \ 71-1 C) <br /> STATE Street Number Street Name <br /> CITY ZIP <br /> �-J c� Al C <br /> PHONE#1 ExT• APN#/ LAND USE APPLICATION# <br /> Q(k�)1 C d3 6 S (� b <br /> PHONE#2 ExT• BOS DISTRICT I LOCATIO C DE <br /> l i ) C( <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS El <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 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 performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. ) <br /> APPLICANT'S SIGNATU1 ��r-,c r, - �Ji�ei DATE: Q <br /> PROPERTY/BUSINESS OWNEILI CJ OPERATOR/MANAGER El ' OTHER AUTHORIZED AGENT ElIf APPLICANT is nnoot 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. -1 <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: E` <br /> SEB _ 5 2001 <br /> GOUNN <br /> SAN JOAOUW EN MENS <br /> ENVIF0 PAR <br /> lTH <br /> ACCEPTED B EMPLOYEE#: r �7 DATE: /• <br /> ASSIGNED TO: o a EMPLOYEE M C DATE: CJ <br /> Date Service Completed (if already co pleted): SERVICE CODE: P!E: <br /> Fee Amount: -2-VS— Amount Paid �S v Payment Date 5Y S 6-7 <br /> Payment Type Invoice# Check# Received-By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />