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SAN JOAQUI"-- 7OUNTY ENVIRONMENTAL HEALEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> '� � <br /> OWNER/OPERATOR -y <br /> i 6 1 r T' L/ Z/ CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME �*✓��/ C / <br /> SITE 0> .�tName'l' <br /> k mb, Direction Str / Ci Zi Code <br /> HOME or MAILING ADDRESS (if <br /> Different from Site Address) <br /> Street Number Street Name <br /> CITY STAT ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 03 <br /> PHONE#2 EXT. BOS DISTRICT / LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR -JCS^� /� 1 Z—Z. <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME ? 1 /' /� PHONE# � _ Ems' <br /> (D f <br /> HOME Or,k4AILING ADDRESS _ Fax# 00Q I f <br /> CITY �/l� STATS, ZIP <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,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ` DATE: � b t? <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT 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 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. F-N-r <br /> TYPE OF SERVICE REQUESTED: Ct cS—r— I�—�'7�Q ( ( i ECEJ Q <br /> COMMENTS: j11r,1 2 2000 <br /> SAN.10AQUIN COUNN <br /> HE NVN DEPAWMEW <br /> ACCEPTED BY: C t LIQ EMPLOYEE#: /j� 3-Z / DATE: Q� <br /> ASSIGNED TO: ���1/v/ EMPLOYEE#: (L�3 / DATE: 6alo } <br /> Date Service Completed (if already completed): SERVICE CODE: 19 PIE: [l j OR <br /> Fee Amount: W ,�(L, ®O Amount Paida 9C f Payment Date 6 Z) 7 <br /> Payment Type LA5 Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />