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SAN JOAQUI OUNTY ENVIRONMENTAL HEAL EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> unl <br /> SITE ADDRESS <br /> Street Number Dip Uon Street Name u—city `1Zin 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 /> WC9 ) 'sl - iclgv <br /> PHONE V ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> A t•,I i i�C`'�1_ � CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME1`5 1 N PHONE# ExT• <br /> 1 n QQ to <br /> HOME or MAILING ADDRE FAX# <br /> 0. 1 ) <br /> CITY Sy &k 1 STATE 6k <br /> ZIP q5j_q <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: kL6h Yl�,�,a� DATE: `t/ <br /> log <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Q <br /> IfAPPLiCANT 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 t the same time it is <br /> provided to me or my representative. iz, /SEN <br /> TYPE OF SERVICE REQUESTED: [D <br /> COMMENTS: SAN/ �UUB <br /> FOA/V QIJiN CO <br /> HEacTy o�PgR M 7Y <br /> M' <br /> ACCEPTED BY: EMPLOYEE#: 2 DATE: <br /> ASSIGNED EMPLOYEE#: / DATE: <br /> Date Service Co leted (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: 42 Amount Paid l)J, M Payment Date 3 2-'1 1Q <br /> Payment Type Invoice# Check# 9 I Received By: �. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />