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a _ jr- <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTEf DEPARTMENT v <br />SERVICEREQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />HOME or MAILING ADDRES <br />FAX # <br />eo <br />OWNER / OPERATO / <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS c�� Q �S i /� fZ-e) <br />(/ / <br />Street Number Direction Street Name <br />cityj Zi Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) (faf Z �j , <br />EMPLOYEE <br />Street NunAw <br />Street Name <br />CITY TATE <br />ZIP <br />PHONE #1 ` ExT• <br />(;0y) ? 7Z <br />APN # LAND USE APPLICATION # <br />- 300- U'• <br />PHONE #2 ExT• BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE RE, QUE <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME i) /� D .n .� �J ;-� � <br />PHONE # ET• <br />HOME or MAILING ADDRES <br />FAX # <br />eo <br />( ) <br />CITY Q O A ZIP <br />R LLING ACKN0NVLEDGF2v1ENT: 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 3 <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, S �and�IFED=�+ <br />APPLICANT'S SIGNATURE: K`- Q �J <br />1)ATF�,.'y <br />PROPERTY/ BUSINESS OWNER 11 OPERATOR/ MANAGER ❑ OTHER AUTHORIZEI)AGENT n <br />If APPLICANT is not the BiLLINGPARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORiNIATION: 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: 412,1-11 <br />CO?IMENTS: <br />q <br />log <br />ACCEPTED BY: <br />EMPLOYEE <br />DATE: <br />ASSIGNED TO: 7/ <br />EMPLOYEE #: %_ <br />) <br />DATE: ^ <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I E: <br />Fee Amount: CS) <br />I <br />Amount Paid <br />`' - <br />Payment Date <br />! ;. <br />Payment Type Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />�Tl <br />