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SAN JOAQUIN-COUNTY ENVIRONMENTAL HEAL�EPARTMENT <br /> 66�r SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# =�SE!527-03 <br /> REQUEST# <br /> Aar, Dc'�tSZC,I N � � <br /> OWNER/OPERATOR ��` <br /> �-�.> / J 1 CHECK If BILLING ADDRESS <br /> FACILITY NAME v <br /> SITE ADDRESS O I -,ter, i/ �J ` ,r�A /)-Tj s)6k---k S2 9 <br /> Street Number Direction ASl�-et Name V(J/` ,J�l Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 E.T. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> V CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# Exr. <br /> 7S �n 1k WO- ( ) <br /> HOME or MAILING ADDRESS FAX# <br /> 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 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 application and that the work to be perf, ill be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ j[/ /S1//�(// <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. 11,w, <br /> TYPE OF SERVICE REQUESTED: �s S' /rl dy rQyl( PIRO G <br /> �COMMENTS: `�a C., Q rl�l(r�'rJ Pais4W <br /> Nd1 V��7 pa�tME�- <br /> sWa��0lt�p�PP�SM <br /> ACCEPTED BY: EMPLOYEE#: Oq- DATE: <br /> ASSIGNEDTO: EMPLOYEE#: 1ZC3 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �Z3 PIE: D <br /> Fee Amount: Amount Paid l.` 6 Payment Date o <br /> Payment Type V IS Invoice# Check# 6 ()1,S t)q Received By: ryZp <br /> � o1 <br /> EHD 48-02-025 64 UP go .07) SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />