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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST ' <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 3 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS O <br /> FACILITY NAME <br /> SITE ADDRESS �-YJ ��`r-17L,-- / De r` 9S.ZuZ <br /> �� Street Number Direction Street Name G—O cHy Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 55Z1C— w n./?U <br /> Street Number Street Name <br /> CITY ^�I• STATE ZIP 9s <br /> �•9-- Z Z 7 <br /> PHONE#1APN# LAND USE APPLICATION# <br /> (Z� 368-ZB/� <br /> PHONE#2 E.T. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS® <br /> BUSINESS NAME PHONE# EXT. <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 laws. <br /> APPLICANT'S SIGNATURE:_51 asl�'��/G <br /> �%moi � DATE: <br /> PROPERTY/BUSINESS OWNER❑ <br /> OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGEMTO, <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 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: <br /> COMMENTS: <br /> s ?p0 <br /> d �rw� TNDFp FN�UNTY <br /> ACCEPTED BY: EMPLOYEE#: DATE: 12 1 <br /> ASSIGNED TO: UWM EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICECOM - PIE: <br /> Fee Amount: N Amount Paid C� r(Sb Payment Date &I p <br /> Payment Type Invoice# Check# 2y S Received By: w <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />