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AANdUAQUIN UOUNTYENVIRONMENTALHEALTHDEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S&o 493S <br /> OWNER/OPERAT�R�jR <br /> �<l h , �P m rn CHECK If BILLING ADDRESS <br /> FACILITY NAME /[ <br /> SITE ADDRESS <br /> [reef Number DimcHan Street Name city Zip 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# +BOS <br /> AND USE APPLICATION# <br /> ( ) 003 C3 <br /> PHONE#2 EXT. DISTRICT LOCATIO C DE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR'J <br /> c� ^ f J / CHECK If BILLING ADDRESS <br /> / ! o <br /> BUSINESS NAME PNONE# Ezr. <br /> 07o as y G s <br /> HOME Or MAILINGADDRESS FAX# <br /> da W, 0-tr 6'-� ( ) <br /> CITY / STATE 64(- ZIP S a C? <br /> BH,LING 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 FE ERAL laws. <br /> APPLICANT'S SIGNATURE: -I DATE: Z —11-512 <br /> PROPERTY/BUSINESS OWNER❑ ERATOR/MANAGER OTHER AUTHORIZED AGENT El <br /> If APPLICANT is not t eBILLING 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 /> Yd.,zrt.,f�� �r�ir.) �i�.►�^al' ��j��G� �aN 1 1 <br /> gPN Nv pONPE MEC[( <br /> ACCEPTED BY' EMPLOYEE <br /> ASSIGNED 7 EMPLOYEE#: � / „ DATE: CY <br /> Date Service Completed (if already completed): SERVICECODE' 3v/5 PIE: 63 <br /> Fee Amount: Amount Paid V I !O o Payment Date 111111,17 I � <br /> l <br /> Payment Type ✓ Invoice# Check# 3 p7 1Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) ' <br /> REVISED 11/17/2003 <br />