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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> T pe of Buslness or Property FACILITY 1D# <br /> SERVICE REQUEST# <br /> Ow IOPE TOR <br /> CHECK If fl& NGADDRESSE] <br /> FACILITY NA <br /> SIrF�qE� lr� <br /> � Street <br /> of n (_Ai <br /> � ` <br /> HOME or MAILING ADDRESS (If Different from Site Address) e <br /> (;IN Street Number treat Nam CC LJ <br /> STATE ZIP <br /> PHONE#i Ext• APN# LAND USE APPLICATION f# 2016 <br /> PrtONe#2 EXT SOS DISTRICT 0q�*EN L HEALTH <br /> i ) . 77F <br /> CONTRACTOR/SERVICE REQUESTOR ENT <br /> REQUESTOR <br /> CHECKIf MILLINcIADDRESSEQ <br /> BUSINESS NAME Q � \C� PHO <br /> 1. ISNE# t I " oezr. e <br /> HOME or(NAILING ADDRESS FAx# `l ] ` <br /> CITY <br /> yt STATE CI Zip S.L3'�rJ <br /> 13LI,LING A NOWLEDGE NT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL IIrAT.TH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or dry business as identified on this form, <br /> I also certify that I have prepared this applicat• n and that the work to be performed will be done in accolxlance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar A and FEDERAL laws, �+ <br /> APPLICANT'S SIGNATURE: DAT}}e&�: L l <br /> PROPERTY/RUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGf,,w <br /> If APPLICANTis not the BILLING PARTY.proof of authorkatlon to sign is required `\ Title <br /> AUTHORIZATION TQ RELEASE INFORMATION: When applicable,I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of Zy 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. p <br /> TYPE OF SERv1cE REQUESTED: �J) <br /> ,. <br /> COMMENTS: O <br /> 4� <br /> ACCEPTED BY: C3 EMPLOYEEM DATE;ra <br /> ASSIGNED TO: EMPLOYEE M. DATE: C _ <br /> Date Service Completed (if already completed): SERVICE CODE: C) I p 1 E; (� <br /> Fee Amount: q-4 + I C)V Amount Pal Payment Date <br /> Payment Type ✓ Invoice# Check# 7 Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> RMASED 11/17/2003 <br />