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SAN JOAQUIN ANTY ENVIRONMENTAL HEALTH Dfi OMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> c)Oct S U'-? ��1, 4( /� <br /> OWNE OPE TOR <br /> Ore.,,+ V /�� / /►a Na �_ CHECK if BILLING ADDRESS O <br /> FACILITY NAME [ �j (� <br /> J 1� 'X tM Gives <br /> SITE ADDRESS Z3 2 q O F P—x <br /> Street Number Direction Street Name dcity Zi✓;ode <br /> HOME or MAILING ADDRESS (If Different from Site Address) •pO !'�c-X /4-79 <br /> Street Number 11�� 1� Street Name <br /> CITY n STATE ZIP <br /> Cs <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> l ► <br /> "76-s—?— 2-:54 S <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1�) ` O I <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEC'C M �© PHONE# EXT. <br /> HOME or MAILING ADDRESSFAX# <br /> CITYj nd STATE ZIP /-s ��/ <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: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPL/CANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1,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: �^i e, �ti✓ �rti e <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: Cf DATE: 1 :7 <br /> ASSIGNED TO: / L EMPLOYEE#: ATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �J-'ZS PIE: [f dS <br /> Fee Amount: "��j c» Amount Paid S Payment Date IZ 20 O <br /> Payment Type Invoice# Check# Received By: L <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />