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SAN JOAQOUNTY ENVWNTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST 40 <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property 000190y E 4009 <br /> E (1 <br /> • OWNER/OPERATOR + CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> city > FC c��� <br /> p ! � Zi Code <br /> ree me <br /> refit Number Direction <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> STATE ZIP <br /> CITY <br /> - ExT. APN# LAND USE APPLICATION# <br /> PHONE <br /> ExT BOS DISTRICT LOCATION,CQ <br /> PHONE#2 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLINGADDRESS❑All <br /> PHONE# Exr, <br /> BUSINESS NAME �'� �,�� Zq 1� y <br /> HOME Or MAILING ADDRESS F �1 <br /> l� STATE c f ZIP ��) <br /> CITY (,Lr,C_ �� <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 plic Ion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar 'STATE nd FED � <br /> APPLICANT'S SIGNATURE: ' DATE: I i <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ Title <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required <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 /> �p� i)c1� ���> �C.uS,�icx�ex' <br /> COMMENTS: "-t' �k',�fic <br /> (2-31 �► P�s�r�Q�rziJ�) `;e VED <br /> NOV - 2 200 <br /> ON <br /> EMPLOYEE#: DATE: E E <br /> ACCEPT BY: T <br /> rc <br /> EMPLOYEE#: �/�� DATE: <br /> ASSIGNED Gr <br /> Date Service Completed (if already co plated): <br /> SERVICE CODE: /q� P/E:g73Q�/ <br /> Fee Amount: �Si� 00 Amount Paid 31A 5 _ Payment Date `� 2 6 <br /> Payment Type <br /> Invoice# Check# L I (o Received By: <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />