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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# AERVICE REQUEST# <br /> OWNER/OPERATOR <br /> lqNJ s— C-_ > / h I ) I CHECK If BILLING ADDRESS <br /> FACILITY NAME + c S(�\ YC-9, AM [�js L1 <br /> SITE ADDRESS l(4)2— <br /> J 1 ►I I �� Al� S c�L� 1C3N SZO ' <br /> Street Number Directio Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 5 Street Number Street Name <br /> CITY S i cock T�� STATE <br /> zIP Q'1 " Z��s <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME J SS`-va `C �� �� PHONE# EXT. <br /> Zc-, -1 L <br /> HOME or MAILING ADDRESS FAx# <br /> CITY < `Zl STATE C I�N ZIP G S 2— <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 and FEDERAL laws. /� <br /> APPLICANT'S SIGNATURE: «r c1 �tirY `^ DATE: <br /> PROPERTY/BUSINESS OWNER LJ OPERATOR/MANAGER 13F1 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 /> 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: © <br /> COMMENTS: /VC <br /> s�✓UiV <br /> Ely DgQUI <br /> NE,q� �M�NTA4 i y <br /> ACCEPTED BY: EMPLOYEE#:Ara �J) DATE: 2� <br /> ASSIGNED TO: EMPLOYEE#: !vV DATE: 2(f 0 <br /> Date Service Completed (if already completed): ZY SERVICE CODE: ob P/E: cg(j--3 <br /> Fee Amount: I LU Amount P I5a, v� Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />