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SAN JOAQ*COUNTY ENVIRONMENTAL HEALAEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ge�- <br /> 5 P-ooio 3Z) <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> A Q. U <br /> SITE ADDRESSI'A i <br /> � VL �I J C..���� � �j2 U <br /> Street Number 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#1 Exr. APN# LAND USE APPLICATION# <br /> LOCATION CODE <br /> PHONE#2 ExT. BOS DISTRIC� <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,STA�E and FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> IfAPPLiCANT is not theBiLLINGPARU 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. A <br /> TYPE OF SERVICE REQUESTED: '— ?!k 71 <br /> COMMENTS: Sq JAN <br /> 110A IjI <br /> HE�rh SME C JJJV <br /> �FPAHrMENT <br /> ACCEPTED BY: / EMPLOYEE#: --�/ 7-0 DATE: 21 i 3 <br /> ASSIGNED TO: �V fZ� EMPLOYEE#: t l��t/, DATE: f 3 <br /> Date Service Completed if already completed): SERVICE CODE: 6 / P i E: Z3 <br /> Fee Amount: Amount Paid Payment Date > r <br /> Payment Type Invoice# Check# Received y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />