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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 6 h h V1, v► h S� "iI <br /> OWNER I OPERATOR <br /> `^n CHECK If BILLING ADDRESS <br /> CY 6 <br /> ✓ <br /> FACILITY NAME V YI � / t <br /> SITE ADDRESS � //nS <br /> G79lreet Number Direction SIR€t me CI ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 2 b 4Y D L b 4 us W ! g T r u e%tre.tNumber Street Name <br /> CITvT—� C.. C e+ zip ] ,j 7 <br /> PHONE#1 EXT. APN# LAND <br /> DD—USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> (ti <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( I <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> also certify that 1 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, STATEypdOFEDERAL laws. <br /> APPLICANT'S SIGNATURE: �Jct?^�C��(J a'-a� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHERAUTHORIZEDAGENT❑ <br /> IfAPPLICANTis 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it i5 available and at theme time it is <br /> provided to me or my representative. s�Y <br /> TYPE OF SERVICE REQUESTED: yl <br /> COMMENTS: P 18 <br /> do <br /> y of qRN u <br /> � p T'�FNT <br /> ACCEPTED BY: ,`/nulA 11 tJ�A1 EMPLOYEE DATE: <br /> ASSIGNED TO: \, �[i v EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICECODE: 1323 P 1 E: E0 O <br /> Fee Amount: Amount PaiV-f�Jlp D� Payment Date Y-1 <br /> 2-0 <br /> Payment Type Invoice# Check# Received By: <br /> 69&- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />