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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1�r I i� Q 001'-� I L 16 <br /> OWNER/OPERATOR <br /> n C�"ie <br /> 0 CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Ut3/'t f <br /> SITE ADDRESS <br /> �-h* 7 N w l(�vt�ta /-k v <br /> Street Number Direction treat Name City Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> I' Street Number Street Name <br /> CITY STATE ZIP <br /> U �('1 <! 3 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (( (v) C� 4 — S—g-`t <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 12 ( CHECK if BILLING ADDRESSO <br /> BUSINESS NAME PHONE# EXT. <br /> �Ag3 S <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 1 , I 'NATE ZIP 3 / <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owne , operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTA HEALTH DEPARTM T hourly charges associated with this project <br /> or activity will be billed to me or my business as identified o is form. <br /> I also certify that I have prepared this application and t the work to be per fo d will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and F RAL IAW . J <br /> SIGNATURE: DATE:��.-PPLICANT'S <br /> OPERTY/BUS ESS ERIIU/ ERAT /MANAGER OTHER AUTHORIZED AGENT❑ <br /> PPLICA T Is not the ILLING 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: <br /> COMMENTS: �VC® <br /> ®V C <br /> >8 <br /> sqN'/oq 2p�9 <br /> ENV Qll/ <br /> h�C l y�E?N7.-tN>), <br /> ACCEPTED BY: EMPLOYEE M DATE: I f^ <br /> "N7,LM QLVI <br /> ASSIGNED TO: n n/v- EMPLOYEE M DATE: <br /> Date Service Copleted (if already completed): SERVICE CODE: S'Z P I E: <br /> m (U� <br /> Fee Amount: ep Amount Paid :)> ,'_ Payment Date <br /> Payment Type Ii Invoice# Check# t Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />