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- SAN JO.AQUY" ",OUNTY ENVIRONMENTAL HEALT�EPARTMENT <br />ST <br />SERVICE REQUE <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />_gQ0 s <br />S <br />OWNER/OPERATOR <br />CHECK if BILLING_ ADDRESS <br />FACILITY NAME <br />J eY\v d — <br />( ) Ll <br />SITEADDRESS�,��SZoc.��h <br />Street Number <br />Direction <br />1j1 D�PAQtjMFMUN7y <br />Street Name <br />CI <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 Ex. <br />I ) <br />APN # <br />SERVICECODE: '1iL <br />LAND USE APPLICATION # <br />PHONE#2 Ext. <br />Amount Paid <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK If BILLING ADDRESS <br />1 <br />BUSINESS NAME - - <br />PHONE# EXT. <br />HOME or MAILING ADDRESS <br />FAx# <br />MAY 12SAtvjo 201VJ <br />( ) Ll <br />CITY STATE C ZIP Q - <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 tbrtllha�ig prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance CoC�es, Standards, STATE and FEDERAL laws. <br />APPLICAN' i'S SIGNATURE: -1-f7/ - DATE: - Z-6qi <br />PROPERTY/BI!SINFSSOWNER❑ OPERATOR/ AGER ❑ OTHER THORIZEP AGENT <br />1. ff APPLICANT is not the BILLING PARTY proof of authorization t0 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 />Drovidedto,lne or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />Vf& <br />MAY 12SAtvjo 201VJ <br />1j1 D�PAQtjMFMUN7y <br />�� NT <br />ACCEPTED BY: - <br />EMPLOYEE#: <br />DATE:6:h" <br />ASSIGNEDTO: <br />EMPLOYEE#: -678DATE: <br />Date Service Completed (if already completed): <br />SERVICECODE: '1iL <br />Pt E: �Z <br />Fee Amount: (, <br />Amount Paid <br />Payment Date S h <br />Payment Type <br />Invoice # <br />Check # ?j 0 ZS (, <br />Received By: �C� <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />