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SAN JOAQOUNTY ENVIRONMENTAL HEALTC)EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5 <br /> OWNER 1 OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> I I <br /> - - <br /> I SITE ADDRESS I° <br /> Street Number Direction Street Name Cit <br /> HOME Or MAILING ADDRESS (if Different from Site Address) r Code <br /> I A/ -ro <br /> . Street Number ��Z <br /> Nam <br /> dew <br /> CITY <br /> STATE 1-114 ZIP 9sa3� <br /> PHONE#1 ! Exr. APN# LAND USE APPLICATION# <br /> Siy0 �--I7d�-�S <br /> PHONE#2 ! EXT. BOS DISTRICT LOCATION CODE <br /> ( } <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR I G/(/;41le � /f <br /> �I �v®' '�"� CHECK if BILLING ADDRESSE] <br /> BUSINESS NAMEEXT. <br /> HOME or MAILING ADDRESS ,n �D <br /> FAx <br /> 3-�;Al - <br /> CITY �� _/ STATE ZIP <br /> BILLING ACKNbWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same <br /> acknowledge g <br /> ge that all site and/or project p J 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 /> ;; <br /> I also certify that l have prepared this application and that the work t be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,,Standards, STATE and FEDERAL laws. <br /> u <br /> APP.LICANT'S SIGNATURE: DATE: / t <br /> ?f <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ S I <br /> If AP,PLIC4NT is not the BILLIA'G PARTt 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, pRY <br /> TYPE OF SERVICE REQCItESTED: <br /> COMMENTS: <br /> �y�'3/tea <br /> CO <br /> �rHD pq�,y CO <br /> i <br /> ACCEPTED BY: l� E <br /> MPLOYEE#: DATE: <br /> ASSIGNED TO: I DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 7 <br /> 2 PIE: <br /> Fee Amount: L C Amount Paid <br /> �. Payment Date 3 <br /> Payment Type L,,— Invoice# Check# <br /> '2,.r Lk L� Received By: <br /> EHD 48-02-025 <br /> REVISED 11/1712003 !� SR FORM (Golden Rod) <br />