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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 (p CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME II n <br /> SITE ADDRESS <br /> L't `�- Street Number Direction StreetName City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> :2D� Street Number L, Street Name C <br /> CITY STATE ZIP <br /> C, A C u <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> I22(-OS <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR \ n <br /> CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME JC\j 4 (� PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 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 <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 application and that the work to be performed will 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❑ OPERA O /MANAGER OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title IIN <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the propeft,qetW)V7' <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at th�/ftp�timc i <br /> provided to me or my representative. '�tU Q <br /> TYPE OF SERVICE REQUESTED: o/l UIN C <br /> COMMENTS: <br /> 9-r'�./ � ��� Cn.�L�1v n ._ ((�jam' �•—r � IVN . <br /> ACCEPTED BY: EMPLOYEE#: ATE: 6 " O - � <br /> ASSIGNED TO: EMPLOYEE#: lJ DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 061 TIE: w <br /> Fee Amount: �Z Amount Paid �SoC Payment Date �( I D <br /> Payment Type , Invoice# Check# Received By: L4'-- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />