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SAN JOAQi•COUNTY ENVIRONMENTAL HEALTI PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (3)a'zD r-.4 coop 019 SR 6 of/4 74, <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS �� <br /> Street Number Direction Street Name cityZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 Err. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE R Err. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR - r <br /> vCHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT' <br /> HOME or MAILING ADDRESS FAX# <br /> C?a�xCIO 60 tLeD ) GAS .. <br /> CITY STATE Ca zip Q <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,Standar ,STATE and FEDERAVIta S. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT IR Ct2r�"C,ce. 411" <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tate <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/ v 4ntal/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is tohe same time it is <br /> provided to me or my representative. �E <br /> TYPE OF SERVICE REQUESTED: (J "AA <br /> COMMENTS: SAN JOACIU�MENTA�SY <br /> HEAD N pEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: 7 DATE: 2 �s <br /> ASSIGNED TO: AJ A EMPLOYEE#: J g DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: Z 3d 81 <br /> Fee Amount: 27 Amount Paid ����' Payment Date 3 1 q <br /> Payment Type L/ Invoice# Check# `Lf l Received By: f T <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />