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SAN JOAQUIopUNTY ENVIRONMENTAL HEALT 4 <br /> EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OW /OPERATOR <br /> ��� Ir try— <br /> � � CHECK If BILLING ADDRESS <br /> FACILITY NAME `+�Y <br /> �IT�DDRESS <br /> �� JJ Street Number Direction X0 knet 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 /> ( ) Z ��d <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CO E <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> _ `� CHECK If BILLING ADDRES <br /> BUSINESS NAME ^ W I PHONE# EXT. <br /> ` �- 4 IV? <br /> FAx <br /> HOME or MAILING ADDRESS 2 o Jkt ( # ) �©CJ — J L/ 2— S <br /> CITY J �R STATE ZIP <br /> BILLING AC OWLEDGEMENT: 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 thisapplication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standa, s, S TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE:(( 9/-7 /0 <br /> PROPERTY/BUSINESS OWNER❑ OPE TOR/ ANAGER ❑ OTHER AUTHORIZED AGENTIL� 1-fe <br /> IfAPPLiCAw is not the BiLLiNGPARTY,proof of authorization to sign is required I I Title IF <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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: A YMLE <br /> C ,E�' Nr <br /> 1,E6 <br /> AUG 7 2001 <br /> Sq N�AQUIN CO <br /> ACCEPTED BY: EMPLOYEE#: pgCF4 ATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 13, P 1 E:2 <br /> Fee Amount: Amount Paid — Payment Date Z <br /> Payment Type " Invoice# ICheck# G Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />