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SAN JOAQU`*OUNTY ENVIRONMENTAL HEALTH&AIRTMElNT <br /> SERVICE REQUEST <br /> Type of Business or Property�+ FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> tl CHECKif BILLING ADDRESS® <br /> FACILITY NAME <br /> SITE ADDRESS f� _J �1? %/9 .S® �' <br /> r Grit d!� G <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) � � � <br /> Street Number Street Name <br /> CITY _ <br /> A7 Ams �a�t�9G°$ STATEK>fi � ZIP VS <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR SERVICE RIEQUIESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> a ev-7 xlcn zllq <br /> BUSINESS NAME PHONE# ExT. <br /> HOME or MAILING ADDRESS o'3 <br /> CITY ®" STATE CLW 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,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ,,. DATE: <br /> PROPERTY/BUSINESS OWNER® OPERA NAGER ® OTHER AUTHORIZED AGENT / 6-4 1/ 1"e- <br /> ��d <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. iQ 1/ <br /> TYPE OF SERVICE REQUESTED: owl <br /> FerkhVA <br /> PA <br /> COMMENTS: <br /> SgNd 3 0 <br /> QUI <br /> ly C <br /> NFgLTH D�A�MIJNTI, <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: S Amount Paid 3'lvr d(� Payment ate 3 �J <br /> Payment Type Invoice# Check# ID Rec rued By <br /> END 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />