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SAN JOAQUIN 06TY ENVIRONMENTAL HEALTH D*RTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />-7-2- <br />OWNER i <br />FACILITY NAME <br />IN <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />CHECK If G BILLING ADDRESS 11 <br />CITY — STATE ZIP <br />PHONE #1 Exr. APN # LAND USE APPLICATION # <br />( )KIIIJI <br />PHONE #2 Exr. BOS DISTRICT _o1k <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR T�dfl <br />zz-Vt 1 0 I Lqx <br />CHECK If BILLING AD <br />BUSINESS NAME - PNON / /7 '77 <br />HOME Or MAILING ADDRESS <br />1160 <br />160 <br />CITY , STATE ZIP17 <br />" <br />rT <br />�4L <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 pr( <br />COUNTY Ordinance Codes, <br />and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: U -- <br />PROPERTY /BUSINESS OWNER❑ E OR / MANAGER ❑ OTHER AUTHORIZED AGENT, <br />I APPLICANT is not the B LING PARTY proof of authorization to sign is require Title <br />AUTIi4RIZATION 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 />Tvee ne Ceovinc Rcnncc7cn• f 1 G.��i o•-i--�yl * � 4 <br />------COW <br />o�rI <br />1 � -f'J C�ti1J� /'; <br />l��J'J,/�Q�--�j/j�^�COMMENTS: <br />l ✓f✓ Y e - ✓ o I xJ " " Rz� ) <br />h �"hp�Qvo <br />ACCEPTED BY: <br />, �i <br />EMPLOYEE #: <br />DATE: OFQ, F <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: ( , <br />Hate Service Completed (if already completed): <br />SERVICE CODE: <br />Ph: <br />Fee Amount: <br />3 <br />Amount Pa <br />3 C� v� <br />Payment Date <br />Payment Type <br />Invoice # <br />Ch9A# 0`t?rq <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />