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SAN JOAQUIN )LINTY ENVIRUNIVIENTAL HEALTF EPARTMENT <br /> *� SERVICE REQUEST 'f <br /> Type of Business or Property -T FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> C ,n, CHECK if BILLING ADDRESS❑ <br /> FACILrrY NAME <br /> SITE ADDRESS + ( <br /> - ,0C) <br /> 0`0()0 Street Number Direction �J Street Name r�'l C€ Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> • <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) —[/� . 7 <br /> PHONE#2 EKT BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRE <br /> SZI <br /> BUSINESS NAME t L LuIU j t PHONE# ' ExT. <br /> `a is <br /> HOME Or MAILING ADDRESS J� FAX# <br /> V (Zo- ) 3 37-0-7Z � <br /> CITY CA <br /> STATE 10� ZIP eq S- � <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,Sta rds, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: ���.-4 <br /> PROPERTY/BUSINESS OWNER❑ PERATORI MANAGER. ❑ OT ER AUTHORIzED AGENT [�� r y1 eco ^� <br /> IfAPPLJCANT is no a BILLING PARTY proof of authorization to sign is required Trite <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: rG� <br /> COMMENTS: <br /> 3611 _,, <br /> SA�►�`tppEPAR {� <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> a:Z <br /> ASSIGNED TO: EMPLOYEE M Ir DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: Amount Paid _ Payment Date <br /> Z .� _ <br /> Payment Type Invoice# Check# y Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />