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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST4 <br /> Jo � <br /> OWNER 1 OPERAT 1R <br /> o <br /> s, C! 4BILLING ADDRESS <br /> FAcitm NAME —r <br /> Srrr ADDRESS {/ O @ T <br /> Street Number ilrg4tlon Street Name rC (� Z LD� <br /> Zi Code <br /> HOME or MAILING ADDRESS (if Different from SIte Address) ­7 r <br /> Street Number Street�a e <br /> CITY STATE IZIPrk <br /> U v I <br /> PHONE#1 E rT APN# L <br /> LAND USE ptlCA-hON#' <br /> r l l-159 I <br /> PHONE#2 ExT• O§ ATRICT LOCATION CODE <br /> r ZP 13 2- 2-5- <br /> CONTRACTOR/SERVICE REQ +ESTOR <br /> REGtUE$TOR <br /> � ! CHECK If BILLING ADDRESS D <br /> BUSINESS NAME v PHONE# ExT• <br /> HomE or MAILING ADDRESSO FAx# <br /> CITY 1 <br /> /Q STATE 6 lJ ZIP P <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />' or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance;with all SAN JoAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE EDERAL s <br /> APPLICANT'S SIGNATURE: DATE: 6 <br /> PROPERTY/BUSINESS OWNERE3 PE TOR AGERJauth <br /> OTHE�AUTHORIZEDAGEN; <br /> If APPLICANT is no the Bt IVG PARTY proorizrflion to sign is required Title <br /> AUTHORIZATION TO RELEASE 1F`ORMATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as',it is available an e time it is <br /> provided to me or my representative. �tiY��'�' <br /> TYPE OF SERVICE REQUESTED: _ \ <br /> COMMENTS: D E C <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> 1 <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: /O EMPLOYEE#: LIPC7 DATE: <br /> Date Service Complete (if already completed)- v ail SERVICE CODE: <br /> PIE: <br /> Fee Amount: Amount Paid1 3 !t <br /> -1$ 1f(0 5, � � � Payment Date <br /> Payment Type Ll� Invoice# Check# 3 Received By: <br /> E H D 48-02-025 <br /> REVISED 1111712003 SR FORM(Golden Rod) <br />