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SAN JOAQUIOUNTY ENVIRONMENTAL HEALTJYEPARTMENT <br /> 1 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPE TOR <br /> + CHECK If BILLING ADDRESS D <br /> sd , L L <br /> k FAciLmr NAME <br /> 4 SITE ADDRESS <br /> /reef um a Direction Street Name Cit Zip Code <br /> HOME Or MAELING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT- APN# LANDUPLICATION# <br /> 1r5/- 77 a -- 05�=?z--`, CLA <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESSE] <br /> BUSINESS NAME PHONE# Exr. 0 <br /> ( <br /> HOME or MAILING ADDRESS FAX# <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 and FEDERAL la <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/13US1NESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is not the BILLINGPARTI, proof of authorization to sign is required Title pa <br /> I AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the propero <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site' st <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at►fffRrtsari}e tune it is <br /> provided to me or my representative. 7 2 <br /> JO <br /> TYPE OF SERVICE REQUESTED: C( LG( 10 60 >4 S`i -0-Dk-ce�-j-,4-77 C--J �QUI•G <br /> COMMENTS: <br /> AL <br /> —T-0 ,� Lf�C 7 c1 �J D F dW(-C 77 n/ -CF-1477G .S <br /> J o <br /> ACCEPTED BY: oL t E LOYEE M DATE: <br /> ASSIGNED 70: S / MPL E#: D • 17. <br /> Bate! c ort;:I if-already e V DE: <br /> Fee Amount: q-3 -p�} mot Pa �} ayme ate �Iived <br /> a� <br />+ Payment Type f In or?e# Check# C/�7 y: <br /> i� (G:oltle Rid <br /> EHD 48-02-025 � �-����T� c.x�..�p� �"� ,d�`7 � 1 <br /> REVISED 11/17/2003 f " <br />