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SAN JOAQ' COUNTY ENVIRONMENTAL HEAL !DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5f=0�2 5 �2 <br /> OWNER/OPERATO <br /> 1 CHECK If BILLING ADDRESS❑ <br /> %'— <br /> FACIUTY NAME \ ` q �� Ake) <br /> SITE ADDRESS `� <br /> Street Number Direction Street Nam cityZi Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (ALpI ) � I C 37- C <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 4 2- <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR oy - CHECK if BILLING ADDRESS <br /> ❑ <br /> BUSINESS NAME PHONE# EXT. <br /> � <br /> HOME Or MAILING ADDRESS ,t a (�# <br /> I <br /> CITY ` `-„�j i.- STATE0-4 ZIP C, <br /> }�f <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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: ' )v-s <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT/ I(I -�(a�Q <br /> If APPLICANT is not the BILLING PARTY,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: T E i <br /> COMMENTS: ��. <br /> MPS ovN� <br /> c <br /> SP E30 pooll Etll N\- <br /> NV P o�PP MENS <br /> ACCEPTED BY: 0 L I it i 4' r EMPLOYEE#: _ 2 / DATE: <br /> ASSIGNED TO: e 14 C p t -7-- EMPLOYEE#: 14 Z Z, DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: P I E: 3 ok <br /> Fee Amount: -4 , �c) Amount Paid O Payment Date <br /> Payment Type ✓ Invoice# Check# ✓' Received By: IR <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> pFvi g=n 11 i1 7i')nnl <br />