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r• <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT•EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />SERVICE REQUEST # <br />PHONE# EmO <br />05 Gam/ <br />EMPLOYEE <br />OWNER/ OPERATOR <br />HOME MAIDN DDR 5 <br />FAX# <br />of /3Dafe <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />CITY DO % <br />STATE C zip <br />G Q <br />Paid <br />Z�-J1 <br />SITE ADDRESS <br />7 f Z <br />� <br />J////�� <br />Street Number Direction P 1/ <br />'/ p <br />Street Name <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />z. cone <br />Cm <br />Street Number <br />Street Name <br />STATE Zip <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXi. <br />(� <br />LO^CATION rO_DE <br />( ) <br />BOS DISTRICT <br />' i'1(l.yXli'c-CPQ <br />CONTRACTOR ir SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME / <br />!`•� DJM EeRN-Kt <br />PHONE# EmO <br />05 Gam/ <br />EMPLOYEE <br />r1/02 <br />HOME MAIDN DDR 5 <br />FAX# <br />of /3Dafe <br />SeNIC¢ COmpl ted (If already Completed): <br />( ) <br />CITY DO % <br />STATE C zip <br />BILLING ACKNOW ,EDGEMENT: 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 I' t' a he work to be performed will be done in accordance with all SAN JOAQUtN <br />COUNTY Ordinance Codes, Standards, and F L laws. <br />APPLICANT'S SIGNAT DATE: <br />PROPERTY/BUSINESSOWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El <br />If APP Is not the BiLL/NG PAx7T 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. -1aI <br />TYPE OF SERVICE REQUESTED: <br />S' <br />COt.,! I ' r ! PR <br />!`•� DJM EeRN-Kt <br />ACCEPTED BY: <br />EMPLOYEE <br />r1/02 <br />ASSIGNED TO: <br />EM: <br />of /3Dafe <br />SeNIC¢ COmpl ted (If already Completed): <br />P / EY_� O r7FeeAmount: <br />O�PaymentType <br />SAmount <br />Paid <br />Z�-J1 <br />7 f Z <br />� <br />Invoice# <br />Check#7 <br />/%33ived By: G�-- <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />