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SAN JOAQUI' l'OUNTY ENVIRONMENTAL HEALT –)EPARTMENT <br /> SERVICE REQUEST <br /> Type of Busi ess or Property FACILITY ID# SERVICE REQUEST# <br /> 1(f, -2-72-C shoo 5 (4 5y <br /> OWNER/ OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS X(/Z / / <br /> P ` On— <br /> Street <br /> 4 <br /> Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> ( ) ( �–'–&—(ve -09 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CON-TRACTOR/ SERVICE REQUESTOR , ,- " ;0 <br /> REQUESTOR CHECK if BILLING ADDRELC9-7 11 Ro cc'T ellS <br /> BUSINESS NAME — PHONE# EXT. <br /> � ZvJ c�> �. C. � �sc ( �i) 53T( El <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP C �/ <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this applicat' n and that the wor o be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STAT and FE RAL laws <br /> APPLICANT'S SIGNATURE: �-' DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERA OR/MANAGER ❑ OTHER AUTHORIZED AGENT 142G'' <br /> If APPLICANT 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: fti ti(� 'L / r t f LA-iV G�Lt <br /> COMMENTS: <br /> ACCEPTED BY: ) A EMPLOYEE#: �� ?�Z-� DATE: 3�� <br /> ASSIGNED TO: �y( C'1U EMPLOYEE#: �,L�-(�` DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: ,r'L 3 P/E: 3 C,Cit <br /> Fee Amount: ��=Z e v Amount Paid - Payment Date 31 B <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />