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SAN JOAQ, COUNTY ENVIRONMENTAL HEALSEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ZOWNE �f�o�► �o S�Z OC)'9 '1 '5 -5-2- <br /> OWNER <br /> R/OPERATOR �n G^ �(� n I CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME � .1/1,'IJ�n,,nG� IL �,•1-��^ I� <br /> SITE ADDRESS � U� <br /> SVeet Number Direction S et Name , vl City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) I oI IFF _ ,tA7�VVWVL--� bVA t Zl <br /> Street Number Street Name <br /> CITY <br /> STATE ZIP 01 <br /> PHONE#1 E;77APN# LAND USE APPLICATION# V <br /> (,2 1) 9IJ- 2 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <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 1 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 , S TATE nd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: UZIDATE: <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 environments �sessnm�ent <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at�+provided to me or my representative. "� � <br /> TYPE OF SERVICE REQUESTED: D(� Qj�/l i oOQ ®� 9 <br /> COMMENTS: +^ 19 <br /> CIV LU �.Irl� I� C �Y V1� H t SON/v N� <br /> EpgRTMFNt <br /> ACCEPTED BY: � EMPLOYEE#: DATE: <br /> ASSIGNED TO: \ J` Y EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 0 P 1 E: I <br /> Fee Amount: L5 Z 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 />