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SAN JOAQUIN _ JUNTY ENVIRONMENTAL HEALTH ,. .'ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> czA <br /> O NER/OP RATOR <br /> / i 1 I A."114 <br /> IV/fN/I Q� CHECK if BILLING ADDRESSO <br /> FACILITY NAME' l / <br /> L <br /> SITE ADDRESS i DOcD- <br /> Str-etNumber Direction (� " ` Na it l <br /> HOME or MAILING 4 ,ADDRE$S (If Different from Site Address) /� ( � -�L) <br /> �' lam' Cif (r6—�t a �`1� �'� It et Number -,7 Street Name iU <br /> CITY $TATE .. ZIP <br /> �' r(i' Tom% Cr, � <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (� -- <br /> PHONE#T EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR OCCHECK if BILLING ADDRESS. <br /> BUSINESS NAME C' l) I �.G�n � �' P /j� ( LA _7rq_1xT. <br /> HOME or MAILING DDRESS100 <br /> (�V Cit�i FAX# v <br /> V ( ) <br /> CITY STATE 0,6r ZIP (^Y <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 /> h <br /> APPLICANT'S SIGNATURE: -CC I f'l u I �� (� V l� DATE: <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 and at thewme time it is <br /> provided to me or my representative. A Y <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: J41V O <br /> y�,�✓�o tN CO o�ll <br /> ACCEPTED BY: - .M N AW EMPLOYEE#: DATE: <br /> ASSIGNED TO: W— EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE: <br /> Fee Amount: 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 <br />