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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST r sP"�IO` <br /> Type of Business or PW" FACILITY ID# SERVICE REQUEST# <br /> 1 C1� 5C oosz-q-o--- <br /> OWNER/OPERATOR I <br /> CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE DES /yam r� <br /> to Street Number D�ectlon t Z o <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'I EXT. APN#_��� i[,� LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME ` �, PLol 7 <br /> HO E <br /> HOME Or MAILING ADDRESS FAX# <br /> ( ) <br /> /), -& <br /> CITY STATE ZIP <br /> r <br /> BILLING ACKNOWLEDG MENT: 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 n that th ork ted will be done in accordance with all SAN JOAQUIN <br /> o e p rform <br /> /0-,-1- <br /> COUNTY Ordinance Codes,Standards, STATE an F DERA <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/M NAGER ❑ OTHER AUTHORIZEDAGENA!� <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. 1 ��el <br /> S�..� <br /> TYPE OF SERVICE REQUESTED: lle f 1JC c 1}1 J!` P <br /> 1 of SuM i� YP c%?9�n PIqG�� 0f � pi <br /> COMMENTS: NC,vJ gir40r." <br /> rD b(� C^J%'S'fv /LTt ' LQ ?�'e� {I C1''t piJ�E� t1�('. Y`� b,E SiJ yr <br /> � SO f Le} P r3-PlU/ CN <br /> �( ' Crit stuF 6.F <br /> V0P20D <br /> b�41nto oCr 07 ? <br /> $A" <br /> ACCEPTED BY: � EMPLOYEE#: DATEH <br /> ASSIGNED TO: �t EMPLOYEE#: DATE: i O1 f a <br /> Date Service Completed (if already completed): SERVICE CODE: F P 1 E: LJd 00-) <br /> Fee Amount: #) Amount Paid 4 E5RPayment Date <br /> 0 <br /> Payment Type Invoice# Check# C) Received By: <br /> EHD 48-02-025 I� t� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />