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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH ItPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Grp c•�J4'�sz- "L- <br /> CPQA <br /> OWNER/OPERAT R _ <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS I t -f- J _.F�vy, 1?,S-3j0 <br /> Street Number Direction FrLw�� Street Name Ci[ Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT" APN# LAND USE APPLICATION# <br /> (.)r7 ) 3�3 j <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR6 <br /> .Q- CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# U 73EXT. <br /> HOME or MAILING ADDRESS FAX# <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 /> 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,SU and ERAL laws. <br /> APPLICANT'S SIGNATURE: JU .� DATE: 4-13 !Z <br /> 'PROPERTY/BUSINESSOWNER❑ RATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> ff APPLICANI is not the LLING 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. P <br /> TYPE OF SERVICE REQUESTED: ��a"I CC/ij�� CC RECEIVE <br /> COMMENTS: FEB 2 012 <br /> SAN JOAQUN LINTY <br /> ENVIRONM MEW <br /> H.EALTH DEPAR <br /> ACCEPTED BY: EMPLOYEE#: DATE: Z r7 <br /> ASSIGNED TO: % EMPLOYEE#: DATE: G' <br /> Date Service Completed (if already completed): SERVICE CODE: ZP 1 E: ( Z <br /> Fee Amount: z ,15— Amount Paid .15b�S p (� Payment Date 12-- <br /> Payment <br /> ZPayment Type Invoice# Check# � Received By: ZIL — <br /> EHD 48-02-025 SR FORM(Golder.Rod) <br /> REVISED 11/17/2003 <br />