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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID-# _-SERVICE REQUEST# <br /> 11 Z l 2 <br /> �' -/ <br /> OWNER I OPERATORr,CHECK if BILuNG ADDRESS® <br /> tl <br /> FACILITY NAME S -�'l(„ v <br /> SITE ADDRESS � I�j I `7 1 <br /> � <br /> c zl toes <br /> Street Number �lon a <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Sheet N=Mber t Name <br /> CITY STATE zip <br /> PHONE#1 ExT. APN N LAND USE APPLICATION R <br /> ( ) <br /> PHONE 92 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR 1 _ ( CHECK If BILLINGADDRE <br /> Ev. <br /> BUSINESS NAME PN " f ��/1 Co <br /> HOME Or MAILING ADDRESS FAx# <br /> CIT STATE 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 /> 1 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,StandarSTATE�aan�d FE�DER,AL laws CQS-� <br /> APPLICANT'S SIGNATU -J l� 1 DATE: I I I y <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER❑ OTHER AUTHORIZED AGENT <br /> If APPUCAAFT is not the BILLING PART►',proof of authorization to sign is required` Title <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 and at the same timi <br /> provided to me or my representative. / <br /> TYPE OF SERVICE REQUESTED: t, <br /> COMMENTS: th v Ct �V�.1`c` IL <br /> L—l/V <br /> �Nry <br /> RT l <br /> Np <br /> ACCEPTED BY: et rV EMPLOYEE 0: DATE: <br /> ASSIGNED TO: t;l,l I EMPLOYEE N: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: D�/ P I E: J C"2 <br /> Fee Amount: — Amount Paid 7 Payment Date -//w <br /> l <br /> Payment Type / s� Invoice# Check (IG Rete ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />