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SAN JOAQ*OUNTY ENVIRONMENTAL HEALT*PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER rOPERATOR <br /> ^t y CHECK if BILLING ADDRESS 0 <br /> FACILITY NAME ` C�J� <br /> Ue. <br /> SITE ADDRESS <br /> 1 Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> Cl STATE ZIP `—I <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#Z ExT• BOS DISTRICT LOCATION CODE <br /> ( <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR AKNS <br /> CHECK If BILLING ADDRESS <br /> BUSINESS E PHONE# Ezr. <br /> C� �-r e S <br /> HOME or MAIL ADDRES FAX# <br /> `7 <br /> CITY \ STATE CA 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,Standardl, TATE and FEDERAL laws. <br /> M1 <br /> APPLICANT'S SIGNATURE: DATE::_ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Et <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required er[e <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: f <br /> COMMENTS: RECEIVED <br /> AUG 2 4 2005 <br /> SAN JOAQUIN COUNTY <br /> 42 4:L xA2 ? RdVIRONM L <br /> ACCEPTED BY: 5-2 <br /> EMPLOYEE#: H DEP ANT Z. _0 <br /> ASSIGNED TO: a f cL '/ EMPLOYEE#: 3 F9 DATE: <br /> Date Service Completed (if already col mp) d): SERVICE CODE: ri Q PIE: - <br /> Fee Amount: O Amount Paid i Payment Date 7 D5 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />