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SAN JOAQUI COUNTY ENVIRONMENTAL HEALT DEPARTMENT <br /> SERV TCE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> O NER/OPERA OR <br /> CHECK if BILLING ADDRESS 10 <br /> FACILITY NAME ✓ <br /> I� <br /> SITE ADDRESS �j� T J�(�f T 7 J-SG <br /> 9"LlU Street Number Direction ,64 � v ree arti€"v" C Zi Code <br /> HOME or MAILING ADDRESS f Different from Site dress) <br /> t!i Street Number Street Name <br /> CITY C STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (131, 4 - <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> a-oC, 9 y�-L <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQU TOR <br /> i ! � , L ' ,' CHECK if BILLING ADDRESS <br /> BU (NESS NAME C— i�— PHONE# EXT, <br /> vc k'& 7—)-6 1�2 <br /> HOW or MAILINrpADDRESS FAX# /Qo I/ <br /> G T' <br /> CITY STATE/�„_ 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 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: � ,c" DATE: qJ 1-71 -2,a <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/.MANAGER OTHER AUTHORIZED AGENT❑ <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. L- ,�n f( / <br /> TYPE OF SERVICE REQUESTED:j 1 L.L S[�l..Cl/ I J/�ZZ Ue <br /> COMMENTS: Rc C EN Ep <br /> APR 2 2 X00 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed : SERVICE CODE: P 1 E: <br /> Fee Amount: I &- Amount Paid �C� a.4 Payment Date 2Z d <br /> Payment Type �—' • Invoice# Check# ' 2(.�� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />