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SAN JOAQUI*UNTY ENVIRONMENTAL HEALTH OARTMENT <br /> SERVICE REQUEST <br /> Type�fBIasiness or Pr p R FACILITY ID# SERVICE REQUEST# <br /> CA <br /> OWNER/ Rt' <br /> .� <br /> 6 <br /> '�/1 CHECK if BILLING ADDRESS 0 <br /> FACILITY NAME <br /> SITE ADDRESS <br /> C Street Number Direction /t' C U/ gtreet N e Ci Zi Code <br /> HOME or MAILING ADDRESS (if ffer t from <br /> SteAddress)CA J <br /> ' 4--5/Street Number Street Name <br /> CITY N'. <br /> STATEZIP 1� y - - <br /> PHO N€#; ���_ J E'�T• APN# LAND USE APPLICATION# <br /> PHOfJ1E#2 ExT• BOS DISTRICT LOCATION CODE <br /> CQNTRACTOR/ SERVICE REQUESTOR <br /> REQUEST QR '� � j 1 CHECK if BILLING ADDRESS <br /> BUSINES AME c ! 11' / PHQNE� EST. <br /> HonnE or MAILING ADDRESS % FAx# <br /> CITY /% STATEl . ZIP <br /> BILLING ACI{NOW EDGEMENT: 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 pplication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar ,IS E and F I S. <br /> APPLICANT'S SIGNATURE: L&w �' ��L DATE'- ICT /,D , J <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required 4 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 /> TYPE OF SERVICE REQUESTED: PAYMENT <br /> COMMENTS: v <br /> DEC 10 2004 <br /> SAN JOAQUIN COM: <br /> ENVIRONMENT:k< <br /> HEAL-TH DixPARTtAFNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 1 -2-10-0v <br /> /) <br /> ASSIGNED TO: EMPLOYEE#: tL+ DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ,q P 1 E: <br /> Fee Amount: Q� Amount Paid 7� — Payment Date <br /> Payment Type Invoice# Check# — Received y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />