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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Busines rope FACILITY ID# SERVICE REQUEST# <br /> C <br /> Ufa �I- 5 -'I• al <br /> OWNER/OPERATORt 1 <br /> \ CHECK If BILLING ADDRESS <br /> an t va <br /> FACILITY NAME �— <br /> SITE ADDRESS `l r1/',�11 1/ - n ✓1 cG <br /> Street Number Direction Street Name / ' Cit l Zip Code <br /> H M Or NAILING AD R SS {7iffere fro�xt Site Address) <br /> L , ( e Street Number Street Name <br /> I-S oz- <br /> CITY k--,j; w � STATE ZIP <br /> PHONE#1X nG APN# LAND USE APPLICATION# <br /> 5 L <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> o Z <br /> CONTRA TOR / SERVICE REQUESTOR <br /> REQUESTOR r <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NA E PHONE# �y /, ,EX. <br /> HOME or MAILING ADDRESS FAX# <br /> L ( ) <br /> CITY STATE ZIP <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,Standar STATE and FEDERAL laws. <br /> r 1 <br /> APPLICANT'S SIGNATURE: �J C DATE: ` <br /> PROPERTY/BUSINESS OWNER❑ PERA OR t MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 DEPARTMEN"I•as soon as it is available and at th)o e time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: 7 �j <br /> COMMENTS: 1' i� C' Y S ✓` 13 <br /> - S4N,/O �02 <br /> /y, EN�IgQ�lh Q <br /> ��Ty�� <br /> ACCEPTED BY: EMPLOYEE#: DATE: j FNT <br /> ASSIGNED TO: �VV 11�WW � EMPLOYEE#: DATE: r 3 <br /> Date Service Completed (if already completed): SERVICE CODE: �� ' P 1 E: <br /> T <br /> Fee Amount: •-� Amount Paid /s� DSI Payment Date <br /> Payment Type Invoice# Check# /D 5 -�1p Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />