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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR '^ <br /> C / 1 1 � CHECK it BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 1 0-0 <br /> r1 �.�Y-.`//V yJ' /� (��/�i-t <br /> cil <br /> Street Number Directio " reel Name V V C -o- Zi C;o <br /> HOME Or MAILING ADDRESS (If Differenl-kom Site Address) <br /> N Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#I E. APN# LAND USE APPLICATION# <br /> tea 001 - 95'l <br /> Ex} BOS DISTRICT LOCATION CODE <br /> CC/t' I..lifl OV l/p <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAx# <br /> 1 1 <br /> CITY STATE ZIP <br /> %[::= 1ILLIN-ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> „ ---:nowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> oractivity 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,$I'pTE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: i � ���— DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 1-1 <br /> 1f 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 /> ab`ve site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> Information t0 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: J6 Vag 1 PAY MENT <br /> COMMENTS: RECEINiED <br /> SOX C�5 { Va �} L�2T S JUL - 6 201 <br /> bAN.IOAQUIN COLN ITY <br /> EVIFIONMENTAI <br /> +=ANTH nEPARTME NIT <br /> ACCEPTED BY: V-� e G EMPLOYEE#: DATE: <br /> ASSIGNED TO: \tJe _I ,� EMPLOYEE#: ^T ` DATE: _ l <br /> Date Service Completed (if already completed): SERVICE CODEC S P f E: - <br /> Fee Amount: a 4 c5� Amount Paid ��t{,`p� Payment Date <br /> Payment Type �� Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM Golden Rod <br /> REVISED 11/171200a ( ) <br />