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SAN JOAQU*UNTY ENVIRONMENTAL HEALTH 10ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Properly FACILITY ID# SERVICE REQUEST# <br /> ��� e S16�c�Li t, <br /> OWNER 10 RATOR <br /> r CHECK if BI NG ADORE <br /> Tle tk-e'd -4 �t)n kn <br /> Facam NAME S-}-0& () \ <br /> SITE ADDRESS `I 06 On <br /> Slmet Number DYeclion Name Code <br /> HOME Or MmmG AQpREss (if ifferertt from Site Address) <br /> / a Sheat Number <br /> CITY STATE C ZIP g <br /> PHONE#f ✓ ET. APN# LAND USE APPUCATmm# <br /> (9 It,) 3 8�--37 It t -31,D--ZG <br /> PHONE#Z EkT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE RE UESTOR <br /> REOIUESTOR <br /> S � � CHECK If BILI.IPIG ADDRESS <br /> BUSINESS NAME PHW# ExT. <br /> HOME or MAILING ADDRESS M I I O�! Fax# <br /> CA q -b ( ) <br /> CRY 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 <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: C�ZDATE: 12- Z 9- O4i - <br /> PROPERTY/BUSINESS OWNER OP TOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑�)�t�(O n Ari\IK / <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1,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 availa"RbiLTsame time it is <br /> provided to me or my representative. ESV EC) <br /> TYPE OF SERVICE REQUESTED: <br /> Comffls: <br /> SAN JOAQUIN COUNT( <br /> HEALTH DEPAR MENT <br /> ACCEPTED BY:/ -EMPLOYEE#: C DATE: <br /> ASSIGNED TO: D EMPLOYEE <br /> Date Service Completed (if a ready ownpieted): SERVICE CODE: P/E: of <br /> Fee Amount: Amount Paid a�� Payment Date 1 j <br /> Payment Type ✓ Invoice# Check# Received By:- , <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />