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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR CHECK If BILLING ADDRESS 0 <br /> FACILITY NAME ( \l <br /> SITE ADDRESS Z.2p� <br /> no �� L(w �\��/,l� c\ 3� <br /> Street Number Direction Street Name l/I I I cit ` 1 J2i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY - STATE C ZIP <br /> PHONE#1 ExT. AP LAND USE APPLICATION# <br /> (NII) X123 p <br /> PHONE#2 EXT. BCS DISTRICT LOCAs N QODE <br /> ( 00) q2S 130�0 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ^ <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# /� EXT. <br /> 20 ISI l� <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <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,STA-1'E andFEDE wS. <br /> APPLICANT'S SIGNATURE: DATE: ZL- 5 —h <br /> PROPERTY/BUSINESS OWNER /O;ERAVGXR�/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT' p6t the BILLING PARTY.proof of authorization to sign is required Title <br /> AUTHORIZATION TOR LEASE 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS' Alf�� I' <br /> )V a 5 <br /> SAN ?019 <br /> HZALT t�CNMFI ouNrY <br /> ACCEPTED BY: EMPLOYEE#: O �� DATE: // /yr <br /> ASSIGNED TO: EMPLOYEE#: DATE: /I <br /> Date Service Completed (if already completed): SERVICE CODE: �Z3 P 1 E: 7�6C) <br /> Fee Amount: I 6oYAmount Paid aj� Payment Date <br /> Payment Type Invoice# Check# Received y: <br /> EHD 025 I O /I SR FORM(Golden Rod) <br /> REVISEDSED 11/17/2003 I �J` <br />