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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 <br /> XI/ Y V l'ICJ r ! CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> La Pif&k_ vl� <br /> SITE ADDRESS l D q a_f rM,y j �� ��,�U� �r C 2 Le,^ <br /> Street Number Dlreetion / ' '�"' Street Name /� Clt Zi Code `f' <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> U r" & Street Number Street Name <br /> CITY tUl� ATE ZIP 1�91n(16 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> PHONE#Z ExT• BOS DISTRICT LOCATioNCODE <br /> { } <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# ExT. <br /> 1 <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, STAT nd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 1� 0/2-2 <br /> PROPERTY/BUSINESS OWNER OP TOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> If f1PPLICANT is not the BILLING PARTY,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 /> I rq) .. chux <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EMD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />