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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/OPERA ORJ <br /> -CHECK if BILLING ADDRESS CI <br /> FACILITY NAME <br /> SIE DDRES$ kf �L A *fitrL.� N <br /> �• Street Number Direction G Street Name Cit Zip Code <br /> HO[MEE 0 MAILING ADDRESS (If Different from ite Address) <br /> �f r Street Number Street Name <br /> C ^ STATE ZIP <br /> tb19PHONE#1 I ` EXT. APN# I LAND USE APPLICATION# <br /> PHONE#Z EXr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME .� �GF � � d PHONE# � Exr. <br /> GG • Sol <br /> HOME or MAILING A SS FAX# <br /> C gas ♦ e <br /> CITY STAT 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: 4�r• A46;-� DATE: Illoolm <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 ane same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: C S C� <br /> COMMENTS: <br /> JO, 4101.9 <br /> Vv 2!1 _ Ov2 r-�o r► 3 3 V1 o U �.� <br /> 1Y, Q41 <br /> FpgRT,y�T <br /> ACCEPTED BY: ,ryL Yr A- EMPLOYEE#: DATE: i 1 Z 2- <br /> ASSIGNED TO: (J� V4 C�4 `' EMPLOYEE#: DATE: `` 7--t/Z l c� <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: ! S Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 I (�1/_/]'m <br />