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SAN JOAQ, COUNTY ENVIRONMENTAL HEAL*EPARTMENT <br /> 1 SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0 7 5 � <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> - I IAF//t.-S1I PA �aS <br /> SITE ADDRESS _- J Y� �t'a V-91, <br /> -ti l Lt l.J ilt t S�avK t bVl <br /> Street Number Direction Street Naitte l city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1 .1"3 PI C-- C1 <br /> Street Number I Name <br /> CITYSTATE Zip O �. <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (�o` ) 1 523 ZZ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. / <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <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 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 /> A(BI L CANT'S SIGNATURE: 9 ,/ - �' <br /> t'./�l1 SJ l l l i-/1 ��/ IJ ATE: 1/4 :3 <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 the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: C C p � t 6 w S bt l �LT 6! t'-\ PAYMENT <br /> COMMENTS: RECFIVED <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: I µr�i t EMPLOYEE M U G l' DATE: <br /> ASSIGNED TO: �� LA EMPLOYEE#: 1 LA,!l DATE: l <br /> Date Service Completed (if already complete SERVICE CODE: d 6 I P/E: l b <br /> Fee Amount: �� j , 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 />