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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -5L�I`0(0 Y y 0 <br /> OWNER I OPERATOR <br /> C <br /> .�' �,`` � CHECK If BILLING ADDRESS <br /> FACILITY NNE G� `l <br /> SITE ADDRESS 20-72? t-1 <br /> / IIs ! _ ��2 <br /> Street Number Direction IJIJ Street ame itl. I Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) / SQeLber LJ � Street Name yn—� <br /> CITY STATE �j ZIP <br /> r � l <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( 'a v8�13 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK H BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING 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 /> 1 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 OWNERt� OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El <br /> IfAPPL1CANT is not the BILLING PARTY proof of authorization to sigh 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, geoteclmical data and/or environmental/site assessment <br /> information t0 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. t <br /> TYPE OF SERVICE REQUESTED: RE NT <br /> COMMENTS: <br /> FEB 11 1011 <br /> ✓SAH JOAQUW COI, <br /> ALT}Irrt°Fhv "D y Nry <br /> AL <br /> EVT <br /> ACCEPTED BY: EMPLOYEE#: DATE: •7 <br /> 1117 <br /> ASSIGNEDTO: j' EMPLOYEE#; O DATE: !/ <br /> Date Service Complete (if already completed): SERVICE CODE: PIE: /Y3 <br /> Fee Amount: -� Amount Paid l L,;7. a. Ob Payment.Date i/ tL7 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />