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SAN JOAQUINUNTY ENVIRONMENTAL HEALT PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> c-\- �A 0�9-36, 7 q <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS '�2 Z y >���^ h� R A 'SN-0 C r"Vfl() 9,S-6.26 <br /> Street Number Direction Street Name Ci Zip 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 /> PHONE#Z ExT• BOS DISTRICT LOCATION CODE <br /> (16`I) 1 3'0 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME — w PHONE# EXT. <br /> -e- o `i6 - 3 <br /> HOME or MAILING ADDRESS FAX# <br /> 2S3S' r. (209) y61 `63`12 <br /> CITY Ns\-oCY\ NJ STATE C ZIP 9s-los- <br /> BILLING <br /> s-1Os- <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 or <br /> 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: 13 - 1 ci —®k ' <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT G� <br /> If APPLICANT is n 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. T <br /> TYPE OF SERVICE REQUESTED: VA�2 T CENE <br /> COMMENTS: 'ZOO <br /> MAR1g n <br /> nil <br /> 1N CavN <br /> • SAN�OAOONMENIAENT <br /> HEP`H pEPARZM <br /> ACCEPTED BY: / EMPLOYEE#: 1 /! DATE: <br /> ASSIGNED TO: {� I EMPLOYEE#: 7 "C DATE: <br /> Date Service Completed (if already'completed): SERVICE CODE: P i E: <br /> Fee Amount: 43 7q Amount Paid Payment Date <br /> Payment Type - Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />