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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> _ SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> � 7s � j <br /> OWNER/ OPERATOR �y) v/� <br /> ��SdCl/ �-iG CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Street--ne Cit; Z10 Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) eq 6cX <br /> ---.— --_ _ Street Number Street Name <br /> CITY STATE ZIP Q 7 <br /> PHONE#1 Ea APN# LAND USE APPLICATION# <br /> PHONE#2 Ex-. BOS DISTRICT LOCATION CODE <br /> ( C"I <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE 4 E,' <br /> HOME or MAILING ADDRESS FAX# <br /> ICITY J r STATE ZIP t fsall d <br /> BILLING ACKNOWLEDGEMENT: 1, 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 activim 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 perti�rnted will be done in accordance with all SAN JOAOt IN <br /> C'0UN'rY Ordinance Codec,Standards, STATE,and Fr:Dt I laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> P'ROPFRTN r Rt-SINESS OWNER❑ OPERATOR/. - AGF.R ❑ 0'1'11F:R AUTHORIZED AGF:NPn <br /> // 4PPLlC..jn r r,�Itot the B/I././A'c P LILY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of'tile property located at the <br /> above site address, hereby authori/r the release of any and all results, geotechnical data and/or environmental site assessment <br /> information to the SAN JOAQtIIN C•I It NTY EN\'IRONMI".NTm HFALTII DIiPARTMENT 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: ov 5,tA/L <br /> COMMENTS: /cR, C.EIVED <br /> 2 013 <br /> SAN JOAQUIN COUNTY <br /> ENVIHOMENTAL <br /> -NT <br /> ACCEPTED BY: EMPLOYEE#: DATE:61 <br /> 2 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E:�> G <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type V Invoice# Check# 7 Received <br /> Golden Rod <br /> EHD 48-02-025 SR FORM( ) <br /> REVISED 11 x1712003 <br />