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SAN JOAQU#OUNTY ENVIRONMENTAL HEALTH OARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACI�SlyyC) SERVICE REQUEST# <br /> VQ� i✓le. �i5 �I✓t LI II �� <br /> OWNER/OP R <br /> CHECK If BILLING ADDRESS <br /> 1 <br /> FACIL 2ECt b <br /> c Yl tom^ � <br /> SITE ADDRESS 6iC i <br /> SIIStroet Number Direction � Street Name C' Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 �JExr. APN# LAND USE APPLICATION# <br /> t coq) �� <br /> PHON #2 EI* BOS DISTRICT LOCATION CODE <br /> P(! ) 7 l <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS❑ <br /> wr tome <br /> PHONE# <br /> Err* <br /> Ei � <br /> BUSINESS l We ( E�n In <br /> ee)cI"n <br /> HOME or MAILING ADDRESS Fax# <br /> I (20e)) <br /> CITY ' y/lr., 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 Coder,Standards,STA ws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/$USINESS OWNER� <br /> _�d/ O TORGER GER 13OTHER AUTHORIZED AGENT 13 <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATIONTO 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 /> i <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: PAYME <br /> RECEIVED <br /> SEP 6 2005 <br /> AN JOAQUIN COUNT`( <br /> ACCEPTED BY: LOYEE#: (/ HEAI �pAR <br /> ASSIGNED TO: EMPLOYEE#: S v DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Q Q P"E:23 0 a <br /> Fee Amount: Amount Paid �Z9 PaymentDate 47 <br /> Payment Type Invoice# Check# R ceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />