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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST SERVICE REQUEST# <br /> FACILITY ID# 5 0D <br /> pe of Business or Property <br /> CHECK If BILLING <br /> VVNER 1 OPERATOR 1('15/V /f r <br /> kciuTY DAME I� <br /> ITE ADDRESSC' Zi Code <br /> k IYI <br /> �7 Street Name <br /> ?.75r Z Street Number Direction <br /> ioME Or MAILING ADDRESS tit Different from Site Address) street Name <br /> O ��x 2 Street Number Zip <br /> $TATE <br /> iITY A/ 7-5 G <br /> LAND USE ATIO CATION <br /> EXT. APN# !!7111 <br /> SHONE#1 <br /> t l BOS DISTRICT LOCA ON CODE <br /> EXT. <br /> PHONE#2 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> REQUESTOR 51';r(go <br /> PHONE# /' / / Exr. <br /> BUSINESS NAME " Q� 2— �'5 <br /> FAx# <br /> HOME or MAILING ADDRESS �o X _7 t <br /> L STATE /,- ZIP L <br /> CITY �� MF�vTlor <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 <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 and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,,STATE and FEDERAL laws, <br /> ' SIGNATURE- <br /> PROPERTY <br /> Z <br /> I'LICANT S SIGNATURE: <br /> _ DATE: <br /> Apf <br /> PROPERTYIBUSINESSOWNER❑ OPERATOR/MANAGER ❑ OTHER AvmORIZEDAGENT❑ <br /> If APPLICANT is not the BILLING PARTY 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 environmentaUsite 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 /> IDA <br /> TYPE OF SERVICE REQt1E <br /> •CONYFMS'" <br /> a <br /> � . . E ►RON+ - <br /> ,A.CCEPTFD BY; ENIPLt]Y E t! Y DAiE:-; <br /> c! <br /> ASSIGNED 70: EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed):Y SERVICE CODE: 2Z PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REV4SED 11tl712003 <br />