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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> OWN R / OPERATOR <br /> CHECK If BILLING ADDRESS <br /> VO\ C <br /> FACILITY NAME <br /> n ac� <br /> SITE ADDRESS I ��c C S -i C C 9 �� A <br /> C1 � <br /> 0 7 2 Street Number Direction Street Name Citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Sit A (dress) <br /> C (J CU Street Number Street Name <br /> CITY STATE ZIP <br /> Sfoc K oe.�\ C 1� 7; S— <br /> PHONE #1 EXT' APN # LAND USE APPLICATION # <br /> c �� ) 3 q6� — C23Z <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> c ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> L J D; i • CHECK If BILLING ADDRESS <br /> BUSINESS NAME // PHONE # EXT' <br /> es � C ✓ >n ���, �• eklor*Xi,tl -Y OV2 (� ° � ) � V6 - 9232 <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, Standard STATE and FEDERAL laws . -7 <br /> APPLICANT' S SIGNATURE : DATE ; C <br /> PROPERTY / BUSINESS OWNER PERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ (7l .J ✓ ` Q V' <br /> If APPLICANT is not the BILLINGPART3, 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 . <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS : <br /> sm Jq Af <br /> 1 2®2 Baa <br /> ENV�gQUby <br /> N Typ pgFNr tN7)o <br /> r4f�-} F <br /> At <br /> ACCEPTED BY: WkA ( <br /> A EMPLOYEE M DATE : <br /> ASSIGNED TO : G EMPLOYEE # : I DATE : 3/ <br /> Date Service Completed (ifready completed) : SERVICE CODE : O / E : <br /> Fee Amount : N e U Amount Pai Payment Date /3 22 <br /> Payment Typq2kfJ. Invoice # Check # ecei ed By: <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> REVISED 11 /17/2003 <br />