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! 0 COPY <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 9-AA-- oo2.la <br /> OWNER/OPERATOR L <br /> �H G �TTS GoNPf�N y CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> 5. <br /> 07~/_S 5AN 00Aauinl country Rfalo^AL GonO4F-71APq F& -11 y <br /> SITEADDRESS 23.390 E F J A L.intpEt� 95 236 <br /> Street Number I DireeNon Street Name city Code <br /> HOME or MAILING ADDRESS (If DWerent from Site Address) <br /> Streot Number Street Name <br /> CITY STATE ZIP <br /> PRONE#1 EXT. APN# LAND USE APPLICATION# <br /> (201) 884" 364.5 <br /> PNONE#2 EXT. BOSDISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS El <br /> BUSINESS NAME PHONE# Exr' <br /> HOME or MAIUNG ADDRESS FAX# <br /> CITY STATE ZIP <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 17 OTHER AUTHORIZED AGENT❑ <br /> .9'APPLICANT is not the B1LLING PART 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: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: <br /> Fee Amount: (�-� Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />