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.� SAN JOAQUVPUNTY ENVIRONMENTAL HEALVEPARTMENT 3 9-4/$DotS <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 /> SITE ADDRESS r J ` S V l I -C� 1� - <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 i ExT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> or IfL6 C/-!� CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAMEg n x/,/ A - � // �SSOCC PHONE# — <br /> /C. �� ��o- 7 7 <br /> HOME or MAILING ADDRESS FAX# <br /> 1(vO (/ALL&CY V/S-7-4 (" )2 � .- 1766 <br /> CITY j�� G � STATE ZIP 4�?% 766 <br /> ING 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 /> I COUNTY Ordinance Codes,Standards,S d FEDERAL laws. <br /> (�[ APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 /> f'V 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: E <br /> COMMENTS: 6 'Ll f05 -Zfi 'i>_;: --i-s abse..re--e � . <br /> 9t'7 i,.._ ►=v�:...✓" ?i�- 200 <br /> JUN 15 <br /> SAN JOAQUIN COUNTY <br /> ,ic-( ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: /�� DATE' <br /> ASSIGNED TO: �!�� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): bon* I SERVICE CODE: e3(y) P1 E: &—r7 <br /> Fee Amount- � , Amount Paid _ Payment Date �B\b <br /> Payment Type L_ Invoice# Check# 7' Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />