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SAN JOAQ ,Y COUNTY ENVIRONMENTAL HEAL,__ DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> f 7, ► � `c � � � <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> I p — "_ <br /> FACILITY NAME <br /> To PL--rao)-caomo -t? t,) <br /> SITE ADDRESS <br /> 7S `) <br /> treet Number rection Street Name kd-cy\ �Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address)1 <br /> 1 , — C Street Number Street Name <br /> CITY STATE ZIP <br /> s - � 9 <br /> P ONE#1 ExT• APN# 7 LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> Ic t L <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 15 MEL— <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME t� ��a/�j y-J! '-7 <br /> 0 fo —� A) PHONE# EXT. <br /> How or MAILING ADDRESS (/v /I /7Il n/� (H� FAX# 6�_ ��(J <br /> 05) <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, /y <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,S TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: PJ7JDATE:2(a 2 12-0 (Lj <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El <br /> IfAPPLICANi 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 atAe same time it is <br /> provided to me or my representative. 4 <br /> RJZ <br /> TYPE OF SERVICE REQUESTED: f Il <br /> COMMENTS: <br /> G � c �s y q N°go�25 � <br /> E4It R0 COV <br /> �Fp ATMFhT <br /> ACCEPTED BY: r JEMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: l <br /> Date Service Completed (if airea y Completed): SERVICE CODE: �" eb� P 1 E: <br /> Fee Amount: `d Amount Pa 1-�5,O D Payment Date <br /> Payment Type f Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />