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SAN JOAQUII` JUNTY ENVIRONMENTAL HEALTl EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> R (i c > ASIC3 mac} v -Z_� .7("q <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> c�I��>T P 6 DG, <br /> FACILITY NAME ) <br /> SITE ADDRESS (.� S L ( <br /> StreeN <br /> t umber Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t ExT' APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR q CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ' <br /> HOME or MAILING ADDRESS 1 FAX# <br /> CITY C STATE L ZIP C(0)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 or <br /> 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 a S. <br /> APPLICANT'S SIGNATURE: DATE: <br /> rr CY�J'-�� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER 11 OTHER AUTHORIZED AGENTt - <br /> If APPLICANT is not the BILLING PARTY proof o,f 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 /> 2 <br /> TYPE OF SERVICE REQUESTED: ( c�'T Y�-- T PAYMENT <br /> COMMENTS: <br /> APR 15 2004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: C / � EMPLOYEE#: L DATE: <br /> ASSIGNED TO: VO A-) rt Ll E EMPLOYEE#: F31 71 <br /> DATE: r4 510 <br /> Date Service Completed (if already completed): SERVICE CODE: t C�� P i E: 3.Ci <br /> Fee Amopnt: �?c7G Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 <br /> SR FORM(Golden Rodd <br /> ocvi ccn+•i i+-7nnnva <br />