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SAN JOAQUM COUNTY ENVIRONMENTAL HEALTholf)EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �lL.00J � <br /> OWNER/OPERATOR <br /> C \ •� CHECK If BILLING ADDRESS <br /> s�V-es DLO-er 1 vfr7� �-LC, <br /> FACILITY NAME ` <br /> SITE ADDRESS e- RSP +1,ra P <br /> GStreet Number I Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) ^ <br /> Street Number Street Name A <br /> CITY STATE ZIP CEIv D <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# 5' <br /> LZ� ) q a 13 l 19 1 -- aLoC7- a SAN J20 O 4 <br /> [PHONE#2 EXT• BOS DISTRICT) OEPA NTA Nim <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> {� <br /> I Ct P�u� S' CHECK If 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 /> 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 nd E RA laws.APPLICANT'S SIGNATURE: DATE: ��/3 <br /> PROPERTY/BUSINESS OWNER❑ OPE R/MANAGER ® OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is not the BILLING PARTY,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: (' e V 1 S 1 C)Yl -C-0 m' I <br /> COMMENTS: a <br /> Cnrrec�-i t� �.) ��GJ�4al e c'ro Y' ,n m <br /> •\y-,CoY �orct� Y1 ;T,r,>o r,o rr 34p oc��s o '7 hoct�s <br /> ACCEPTED BY: �� f -�t� EMPLOYEE#: 2, �/� DATE: 2- <br /> /S <br /> ASSIGNED TO: EMPLOYEE#: "Z DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: `� S' PIE: J <br /> Fee Amount: Z Amount Pai J.DD Payment Date a <br /> Payment Type t/ Invoice# Check# Received By:Nr:f <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />