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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> H-D +- 6 o �& [;W-3 <br /> 0WNER/OPER'ArT0R� f1 R� CHECK If BILLING ADDRESS <br /> /V � iA_I�VIrA1 <br /> FACILITY NAME �t <br /> SITE ADDRESS '(�/✓ 11/i > �� 1 'O�l '\ <br /> '0Z� i'L Street Number Direction (7 rest Na � CI Zip Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (2oL�o &03 "8 Z0-r- <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR �` <br /> l CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> HOME OH 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 1 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 <br /> APPLICANT'S SIGNATURE: 9--` e-1 X LDATE: <br /> PROPERTY/BUSINESS OWNEREr OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ 1 <br /> IfAPPLICANT is not the BiLLiyG PAR 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 environmAeen'-tal/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available an��yP�same time it is <br /> provided to me or my representative. �r/ry`1J��cc <br /> TYPE OF SERVICE REQUESTED: `D <br /> COMMENTS: <br /> SANdOAQU/ ZQ22 <br /> FNV! N C <br /> M TH UO p At <br /> ACCEPTED BY: �v f� <S C-0 EMPLOYEE#: DATE: _ �Z <br /> ASSIGNED TO: CKN EMPLOYEE#: DATE:tO^_ <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: ( O <br /> Fee Amount: Amount Paid /5�.D�!) Payment Date g 3( ZZ <br /> Payment Type GI Invoice# Check# I Z�s Z3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />