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-0 G-(rD ,nA C- P('� 0_S <br /> SAN JOAQUIN CO ENWIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Ty,�5pe of Business or Property FACILITY ID# SERVICE REQUEST# <br /> � �1�4 <br /> OWNER/OPERATOR <br /> ���GrtifQ� CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> �J r✓s" �1 <br /> SITE ADDRESS /�/ <br /> '1� Street Number irect�on ��N me ` �TDC city FZi Code <br /> HOME or MAILING ADDRESS (if Different from Site Add s) <br /> V= t_L'J Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr. ApN# LAND USE APPLICATION# <br /> PHONE#2 Exr. BOS DISTRICT LOCATIO CODE <br /> ( ) cl�- 2 � H <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1e.X�1 <br /> CHECK if BILLING ADDRESS I,G� <br /> f10►_ Ll f I Y�v�-- <br /> BUSINESS NAME PHONE# ExT. <br /> HOME or MAILING ADDRESS FAx# <br /> r--, 1-11 ( ) <br /> CITY ` STATE ZIPCA <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 I have prepared this application d that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and DER-AL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUsrNFSs OWNER❑ OPERATOR/ A.NAGER ❑ OTHER A[THORIZEDAGEN'T� <br /> If APPLICANT is not the BILLING PA 7Y•proof of authori;ation to sign is required Uiti, <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 releaslt of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COt'NTY ENVIRONMENTAL HEALTH DEPARTMFNT as soon as it is available and at the Came time it is <br /> provided to me or my representative. I® <br /> TYPE OF SERVICE REQUESTED: C C � <br /> COMMENTS: ZO <br /> �rtia�AMF�a� <br /> c- d e -,j I�1-) i nG <br /> M <br /> ACCEPTED BY: EMPLOYEE#: DATE: -Z 7—� <br /> ASSIGNED TO: b EMPLOYEE#: DATE: /._ <br /> o lY t� I Z l f- <br /> Date Service Compl ed (if already completed): SERVICE CODE: S 2 P I E: / <br /> Fee Amount: Arnunt Pal 7���� Payment Date 9,2$ 8 <br /> Payment Type Invoice# Chock# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />