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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS <br /> ,4nl�i D�L.BP.�zg,4 <br /> FACILITY NAME <br /> SITE ADDRESS I o7c�' o �� <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 420" W, C—AAJ <br /> —It <br /> _,Street Number Street Name <br /> CITY ^ ' STATE C� ZIP <br /> PHONE#1 '!�V EXT APN# LAND USE APPLICATION# <br /> (W1) 466; 4785 ��—' 220^0°> PA -07-F0z <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR �( <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME I PHONE# EXT. <br /> D/u,on! �Mv2P�l 2,9-t 334-661.3 <br /> HOME or MAILING ADDRESS DO `�, 0'r 090 (Ax# ) 3 —0-7Z3 <br /> CITY �O�/ r STATE �� ZIP �CJ 2 <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 <br /> or 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 EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: v� <br /> PROPERTY BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT 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 environmentaUsite 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. �, n <br /> TYPE OF SERVICE REQUESTED: P`Y`v` �U <br /> COMME TS: (��,-.+-� ���1 MJ \ �, L�tl� <br /> Com ME /� v 1 o�uL . <br /> SAN JOAQUIN C�ASTM <br /> ENVIR�NPP <br /> NEp,LTH DEPARTMENj <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: l Amount Paid [� r Payment Date <br /> Payment Type ✓ Invoice# Check# Received Byes <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />