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SAN JOAQL. COUNTY ENVIRONMENTAL HEALT EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY IQ# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> � !r <br /> SITE ADDRESS ,� L] o f ��5 Z-L/ <br /> Street Number Direction 6lreet Name C/LCit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> -7 S=S� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK It BILLING ADDRESS <br /> BUSINESS NAMEJ) PHONE# rl �T. <br /> l Com. !- /! 3 <br /> How or MAILING ADDRESS F x ����7 _C 2 / <br /> Po ( ) O JJ <br /> CITY r STATE C A 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 EwiRoNN ENTAL 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 1 have prepared this application and that the work to be performed will he done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. ,� <br /> APPLICANT'S SIGNATU DATES\ <br /> PROPERTY/BUSINESS OWNER O OPERATORIMANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property Iocated 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. PAS <br /> TYPE OF SERVICE REQUESTED: tiE <br /> C /O CFF <br /> COMMENTS: / 2 6 20;3 <br /> SAN NO F QUIN CpU <br /> NC'4L71i tUiNLNTAL <br /> t1L rlfaF7TME N i <br /> ACCEPTEL BY: EMPLOYEE#: DATE: <br /> ASSIGNED To: EMPLOYEE#: DATE: tC <br /> Date Service C pleted (if already completed): S RVICE CODE: s PIE: <br /> Fee Amount:, d v Amount Paid .D� Payment Date 3�� I3 <br /> Payment Type V1` Invoice# Check# Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 54 ,�— <br />