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SAN JOAQUL, 42OUNTY ENVIRONMENTAL HEALTH ,0ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> GL.)n Oe LUT J CHECK If BILLING ADDRESS <br /> FACILITY NAME r�-�f <br /> SITE ADDRESS C C <br /> ,r) - C - 1(?ti�'7` GT Svc"(�rJ /5 05 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> DTIC tcc1/ ) �i� / Street Number Street Name <br /> CITY STATE ZIP <br /> C A'7—Wo <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (?LIT 61s` 8330 ��13�3 V 4J . <br /> PHONE#2 ExT• BOS DISTRICT LOCATI N CODE <br /> cZi"() ) C('L 6c o 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS13 <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 <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,Standards,STATE and FEDERAL laws. <br /> Ct <br /> APPLICANT'S SIGNATURE: n du it)P-e (" , —�a f` :2 DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ 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 ENv1RoNN ENTAL HEALTH DEPARTMENT as soon as it is available and at the s time it is <br /> provided to me or my representative. y <br /> TYPE OF SERVICE REQUESTED: i�vp� t�� L � <br /> COMMENTS: L r A � /�' AHJD � I <br /> cod>if <br /> EAg9TTq�N <br /> MFNr <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: 1 <br /> Date Service Completed (if already completed): SERVICE CODE: �i3 PIE: <br /> C rp <br /> Fee Amount: 6 Amount Paip, 37.5•vPayment Date 313 t <br /> Payment Type V Invoice# Check# S/-707 Rec ived By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />