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JAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT <br /> SERVICE REQUEST <br /> Type o `siness or Pr pe y I FACILITY ID# SERVICE REQUEST# <br /> 556 IL d ��(5 z:4- <br /> OWNER <br /> OWNER OPERATOR � <br /> CHECK If BILLING ADDRESS <br /> i W <br /> FACIUTY NAME <br /> SITE ADDRESS <br /> Streerdddd'/b <br /> rection ( k�� Street Name ��(C//►/ i �" Zio Code <br /> HOME or MAILING ADDRESS (I Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PH <br /> EXT. APN# LAND USE APPLICATION# <br /> C)4 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 11 v <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CvV <br /> CHECK If BILLING ADDRESS <br /> /n <br /> BUSINESS NAME `, PH EXT. <br /> LS�7 <br /> i <br /> HOME Or MAILING ADDRESS �, Fes) 4(E )���� <br /> CITY STATE ZIP 9L) <br /> `.,L ll <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 appli 'on and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST ;and FEDERAL 1 i , <br /> APPLICANT'S SIGNATURE: / DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is require 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. <br /> TYPE OF SERVICE REQUESTED: S/ CEI r <br /> COMMENTS: �l.T 3 O 20 <br /> 841V,/0 08 <br /> ENW AQUlty C <br /> NST ,01V A4,,: <br /> ENT <br /> ACCEPTED BY: EMPLOYEE#: 4APID <br /> DATE: <br /> ASSIGNED TO: EMPLOYEE#: Z, DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: 2 <br /> Fee Amount: 1-1� vo Amount Paid s 6v Payment Date 1 13a g <br /> Payment Type Invoice# Check# 1 314 Received By: C('� <br /> EHD 48-02-025 SR FORM(Golden`Rod) <br /> REVISED 11/17/2003 <br />