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I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property rrIlFACILITY ID# SERVICE REQUEST#rr <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> -F� <br /> SITE ADDRESS ,,C 7,S }"1 Kt I �t� �/1 ��,f��U 11 �7 l f�,� <br /> /Street Number Direction Street Name 7' Cit Zi Code <br /> HOME or MAILING ADDRES 7(If Different from Site Address) <br /> �CT Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> (may <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUE$TOR VA 9 , <br /> ( D` 0A L ON 6 CHECK if BILLING ADDRESS <br /> BUSINESS NAME 4 PHONE# i EXT. <br /> r� 1� 2 A {�I�q� q S �- G ] 3 y <br /> HOME Or MAILING ADDRESSl qJ b v J G a a` -Co � V k' [AX# 1 <br /> CITY r -P i' <br /> I� STATE C' ZIP k-A O <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,Standar LTATEand FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: r z ' <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER J0 OTHER AUTHORIZED AGENT GI <br /> Iff1PPLICANT is not the BILLING PARTI,proof of authorization to sign is required ClIvile <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 Ibl the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 4%4/1yQUD <br /> E�My <br /> Naaqt ' <br /> ACCEPTED BY: EMPLOYEE M. DATE: ' 4V <br /> ASSIGNED TO: + + i EMPLOYEE#: v DATE: <br /> Date Service Co pleted (f already completed): SERVICE CODE: J P/9: <br /> U� <br /> Fee Amount: V Amount Paid f Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 � a{���Nq <br />