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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5 C) 0 C;L -50. 1 �s <br /> OWNER/ OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME t J <br /> SITE ADDRESS 13 3 C: 4 V1/ HA M rn;;/z 4, Arles _Src-c% L/ <br /> Street Number Direction Street Name City 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• N# LAND USE APPLICATION# <br /> (� v 4f- -7-, 3 ,7 7,t2 <br /> Z/-7,0 -.13 <br /> PHONE#2 EXT. BOS DISTRICT A / LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> [ y— CHECK If BILLING ADDRESS <br /> BUSINESS NAME ` r / PHONE# ExT. <br /> FE (;z&q ) 4/0- t- 337 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIPA. <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 F'EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: /�� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/Mnty R ❑ OTHER AUTHORIZED AGENT S Cl / �° /"� h/?, <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. <br /> RF <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: APR 1 <br /> SAN JOAQUIN Co iwy <br /> ENVIRONME <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE:" <br /> Fee Amount: Amount Paid a g �' Payne Date ( "7 <br /> Payment Type t Invoice# Check# _ Received By: <br /> EHD 48-02-025 ` SR FARM(Golden Rod) <br /> REVISED 11/17/2003 V <br />