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4rNANJO'AQUIM pOLIN:F7 -,L—NrVIRONIIZENTtAL-ItEALM IVOE-• ThtENI <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERACE REQUEST# <br /> nn ayqnu�OWNER/OPERATOR ...k J <br /> Cf1EpC 11 BILLING ADDRESS <br /> FA m NAME <br /> SATE ADDRESS IN <br /> Street Number Direction Stre Name ctty Code <br /> HOME or MAAUNG ADDRESS (If Different from Site Address) (� <br /> Street Number Street Name v ? <br /> CITY STATE ZIP l <br /> Q <br /> PHONE#1 EXT. APN tF LAND USEAf'PucAnom <br /> t ) <br /> PHONE#T ExT• DOS DISTRICT LOCATION CODE 4) <br /> ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CnEcKIf DiLuNG ADDRESS PHOKE# tBUSINESS NAME - EXT. <br /> HOME or MAILJNG ADDRESS /© , /1 FAX# <br /> CITY / � STATE Z1P <br /> AILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of camp <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 Fi D RAL laws. <br /> APPLICANT'S SIGNATURE: �G(r, DATE: -- <br /> I'ROPMTV/RUSUNIESS OWNER L1 OPERATOR/MANACER ❑ OnisR AvmioxrLED AGENT❑ <br /> IfAPPUCANT is not the BILGING EdR7Y 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 environniental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HF,ALTH DFPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative- ^Q <br /> TYPE OF SERVICE REQUESTED: RECEIVED� <br /> OCT 11 2004 <br /> SAiq-J0A0UIN COUNTY <br /> ENVIRONMENTAL LC <br /> f��dDEP'/�37 , <br /> TMENT <br /> ACCEPTED BY: �� EMPLOYEE#: <br /> ASSIGNED TO: EMPLOYEE#: ��� DATE: <br /> Date Service Completed (if already completed): I SERME COOS: P I E: <br /> Fee Amount: Amount Paid Payment Datocr <br /> /.� <br /> Payment Typo Invoice ff Check# Received icy: <br /> EHD 4"2-025 SR FORM(Golden Rod) <br /> REVISED 11117(2003 <br />