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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SPACE RQEQ(UEST# <br /> j��1�- 1�1�11�i1 �QVN � dv LZ�� 1 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS s �fi Joe, �, G15 203 <br /> 1016 Street Number I e Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (ICA 3(r (0 <br /> PHONE#2 EXT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR n <br /> (jy)✓'l � � V-kv) I CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> ko ie ,S��UIc� lv�� 2C� <br /> HOME or MAILII7NG AD ESS / FAX# <br /> CITY S�� STATE C- ZIP o-s'-L L), <br /> BILLING ACKNOWLEDGEMENT: 1, 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:�dlldll� ��n���n DATE: :3, �I 2c,20 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER O 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. ILA "r <br /> TYPE OF SERVICE REQUESTED: IMh LVED <br /> COMMENTS: <br /> IAN 2 � 202 <br /> Q04 COUNTY <br /> SAENVIRONM RSMENT <br /> HASH DEPA <br /> ACCEPTED BY: / EMPLOYEE#: DATE: 7jt� <br /> ASSIGNED TO: EMPLOYEE#: DATE: 11A <br /> vv <br /> Date Service Completed (if already ompleted): SERVICE CODE: /I jp PIE: <br /> Fee Amount: Amount Paid l S Z PaymenntTTDate f �l Z--e-7 <br /> Payment Type ,a Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> REVISED 11/17/2003 <br />