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SAN JOAQUIN COUNTY ENVIRONMENTALHEALTHDEPARTMENT <br /> SERV-CE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQU{ESrT-�# <br /> 5 (�00' l l <br /> OWNER/OPERATOR i <br /> CHECK If BILLING AODRE55 <br /> FACILITY NAME <br /> SITE ADDRESS /OD L� Lr P��p© Q�� G'�� 5z <br /> Street Number (D-i-reJction Street Name •�✓ Ci Zi 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 APPLICATIONN# <br /> ( ) ' A — Sco lC <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR / a / CHECK If BILLING ADDRESS® <br /> BUSINESS NAME PHONE# — EKr' <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY / STATE c-, ZIP /s'1 <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.. /7 <br /> APPLICANT'S SIGNATURE: DATE: <br /> C!J � �3 –'C�C7 <br /> PROPERTY/BUSINESS OWNER❑ 0141IRATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT 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 /> infom7ation 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: 2, 3 <br /> 2006 <br /> SP�'t JQAQUIN xx- <br /> �f-01 /a/I' N�ItR�DEPARTMEtSf <br /> (L/� HFA <br /> ACCEPTED BY: /U EMPLOYEE#: DATE: <br /> ASSIGNED TO: �/ EMPLOYEE 6366 1 DATE: <br /> Date Service Completed (if already completed): SERVICE C�E: -J, P i E: <br /> Fee Amount: l CJ' Amount Paid .i - ate <br /> �. <br /> Payment Type Invoice# Check# °� .A Received By: <br /> EHD 48-02-025 '_SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />