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SAN JOAQUIN COUNTY ENVIRONMENTALHEALTHDEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property F=ACILITY ID# SERVICE REQUEST# <br /> A&A4,6w, 12gtvqL�7 (41 <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FAcli_rrY NAME <br /> SITE ADDRESS <br /> ad Street Number Direction Street Name �c ci Zip Code <br /> HOME/Or/MAILING ADDRESS (If Different from Site Address) <br /> .2 c-2-/��� ��� Aore. Street Number Street Name <br /> CITY STATE ZIP <br /> , :;;4. <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> ( 1 -3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS WAMEPHONE# EXT. <br /> G',1�.� ��Q� � •-� .� � ( 1 tea- -.� <br /> DOME Or MAILING ADDRESS <br /> FAx# <br /> 2 f ( ) <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 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE DERAL laws. 11 <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER EP to R/MANAGER OTHER AUTHORIZED AGENT IS <br /> IfAPPLIcANT is not the BILLING PARTY,proof of authorization to sign is required FWME��-} <br /> i AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the pr4&gyAok\dt at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site as�LC1541S��71ent <br /> inforrriation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and go* sante t4melt is <br /> _ provided to me.er-my-representative. • _ U1T`f <br /> NTAL <br /> TYPE OF SERVICE REQUESTED: ~ �� G�n{�t L(�7'r�jZ(i tV ENVIRQNpAETM-tlT <br /> COMMENTS: <br /> ACCEPTED BY: ®LC JFt ,/JEMPLOYEE#: 31 <br /> DATE: <br /> � <br /> ASSIGNED TO: T—(V 6 �'� EMPLOYEE#: bel I DATE• a f Os" <br /> F Date Service Completed (if already completed): SERVICE CODE: Q P I E: "t'�aL <br /> Fee Amount: Amount Paid OD Payment Date a S <br /> Payment Typo L� Invoice# Check# O Received By: N (� <br /> END 48-02-025 p;SFS-FORM:(G.olde'n'Rod) <br /> REVISED 11/17/2003 <br /> t <br />