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SAN JOAQ COUNTY ENVIRONMENTAL HEALT,. ?EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATORJ v <br /> als <br /> FACILITY NAME Ae-\ <br /> 1�`�� 1 v, n `� �EKIfBILLINGADDRESS� <br /> 1 f� lJ� <br /> SITE ADDRESS L/ <br /> Street Number Direction ' tee ame Cit Z' Code <br /> 1-101% r MAILING{DDRESS (It Different from Site Address) \�`-t� k�� <br /> Street Number 1 Street Name <br /> CITYSTATE��� ZIP n,5 <br /> PHONE#1 ExT• 7PN# LAND USE APPLICATION# "I v <br /> (Zb� �1�� k1b <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR t 1 �i <br /> L Ck CQ �S CHECK If BILLING ADDRESS <br /> BUSINESS NAME —\ PHO <br /> HOME or MAILING ADDRESS FAX# L <br /> CITY rr /, STATE n/i, ZIP q <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 /> 1 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,Standards, S' and FEDERALAWS <br /> APPLICANT'S SIGNATURE: - 4�� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT 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 avai� n�lidai the same time it is <br /> provided to me or my representative. T MCC�`ry��� <br /> TYPE OF SERVICE REQUESTED: KMEIVED <br /> COMMENTS: NOV 0 5 20 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY:C�(��(�(�( �rl� ��J� EMPLOYEE M DATE: <br /> ASSIGNED TO: v �� � 1 'l EMPLOYEEM (7`K—YL DATE: ��`C \ <br /> Date Service Completed (if already completed): SERVICE CODE: o <br /> Fee Amount: - J�' UU Amount Paid Payment Date �, S /7 <br /> Payment Type % Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />