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3Aly dVAVUIIN I.UUN I Y EN VIRUNIVIENI'AL HEALTH DEPARTMENT <br /> y SERVICE._REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> � V VF/ <br /> OWNER/ OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS / �e /v �„ C T-72,q U <br /> Street/Number Direction / Street Name cityZi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICA ION# <br /> C15 3 Pre "17 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / q 4, <br /> 4 CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> ( Zt <br /> HOME Or MAILING ADDRESS Fx)I CA /t�� FAX# 7 <br /> CITY40y� STATE � A ZIP <br /> CJ/ <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 a FEDERAL law . <br /> APPLICANT'S SIGNATURE: �r �_7C> �C� L DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ THER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of at lorization 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. <br /> TYPE OF SERVICE REQUESTED: 1P1-\1 IV— <br /> COMMENTS: Q C�`��� <br /> �OAQUIN GOON <br /> SA ENVIRONMEN'k- <br /> R <br /> ACCEPTED BY: ��j �� _ EMPLOYEE#: O TE: Gr <br /> ASSIGNED TO: A � EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: '3 S PIE: <br /> Fee Amount: �(� Amount Paid C �� Payment Date (i <br /> Payment Type Invoice# Check# Received By: — <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />