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I <br /> ' SAN JOAQUIN UNTY ENVIRONMENTAL HEALTPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property F/ACI�LLIIITIY ID//%# (SfEla(RNV/ICE R(�E/QU(]'��E�ST# <br /> —F' 1 / ),— l l / I�V V S 1 J <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAMEnVinn) 'T <br /> - d <br /> SIE S [,Cc\� 9 52 l <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CIN STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2M) 56`1 - (9 tO 2S'- 190-t <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 1 ` <br /> CONTRACTOR / SERVICE REQUESTOR <br /> [REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME PH E X� <br /> ( <br /> HOME or MAILING ADDRESS ^ FAX# <br /> G <br /> CIN STATE ZIP <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ( <br /> -�W-I '� ,�" DATE: 'I.-- `--L _ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT'a (� 1 , Cnlks <br /> If APPLICANT 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 and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: (� '7` f�i EPAYMENT <br /> COMMENTS: <br /> Nkudfawn <br /> SANNV <br /> ENVIRONMENTAL <br /> TM <br /> MENTAL <br /> HEALTH DEPARTMENT�y <br /> ACCEPTED BY: .n .1 EMPLOYEE#: (,3 Z� DATE: 7 /Wok <br /> ASSIGNED TO: _p EMPLOYEE#: `r TE: -71 (7/0 6 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> 3�j <br /> Fee Amount: cZ Amount Paid Payment Date <br /> Payment Type v/" Invoice# Check# , ` (D Received By: - <br /> EHD 48-02-025 SR FORM(Golden"Rod) <br /> REVISED 11/17/2003 <br />