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SAN JOAQUu-, COUNTY ENVIRONiVIENTAL HEALTh EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ' cW( -F000 lees T S I S�2 o U'10 3 3K <br /> OWNER/OPERATOR <br /> o60- CHECKIf BILLING ADDRESS <br /> U LY l til (�I�SPsy— <br /> FACILITY NAME <br /> SITE ADDRESS Cj, JU 21 L�kVeqs-2 3� <br /> Street Number Direction Street Name Cit `7 Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> NGT Street Number Street Name <br /> CITY STATE_ - ZIP q C-3 O <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) 00 C <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE 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 <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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: r 670I(q DATE: ZS �Z <br /> PROPERTY/BUSINESS OWNEak 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 aPA jlae same time it is <br /> provided to me or my representative. ��j J EN <br /> TYPE OF SERVICE REQUESTED: �7U0 N S(A CT IQ/r 0 A ' ~ `D <br /> COMMENTS: 2014 <br /> SAN jO <br /> n , ENVQUIN COU <br /> NE4LTH pOWNTALFI Y <br /> T <br /> ACCEPTED BY: EMPLOYEE#: DATE: D <br /> t;' / <br /> ASSIGNED TO: L w J 1 " / EMPLOYEE#: DATE: <br /> Date Service Completed (if alr y completed): SERVICE CODE: P IE: <br /> Fee Amount: 7�(� Amount Paid ���-bb Payment Date g l <br /> Payment Type Invoice# Check# 3 Recei ed By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />