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SAN JOAQt11N COt:NTY ENVIRONNIENTAI, HEA1.`Fli DEPARTMENT <br />SERVICE REQUEST A -P-- D ()0 Li ? S�3` <br />Type of Business or Property <br />FACILITY X <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />/ ? j� R � <br />—(�&7�/� <br />` <br />CHECK If BILLING ADDRESS <br />FACILITY NAM�.D <br />r �jGG✓ <br />DATE: <br />SITE ADDRESS <br />...J Streal Number <br />/ v <br />ID•I�rectlon <br />/� ./� A. �.1�"Z' L <br />Street Name C...- <br />CI <br />ZipCode <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE <br />ZIP <br />REM <br />Payment Date <br />PHONE #1 EXT. <br />( ) <br />APN # <br />Payment TypeS <br />LAND USE APPLICATION # <br />I MAY 0 6 <br />PHONE #2 EXT. <br />( ) <br />3 3� <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQI'ESTOR <br />ED <br />015 <br />HEALTH <br />PERMIT/SERVICES <br />REQUESTORyc-�j A ^ `� <br />.� ! �' C CHECK If BILLING ADDRESS <br />BUSINESS NAME^ ,� l <br />A <br />PH N - 3 /�T• <br />� <br />HOME OLMAILING DpRESS A� -^� � <br />� <br />FAX # — <br />CITY STATE ZIP <br />BILLING ACKNOIN'LEDGENIENT: I. the undersigned property or business owner, operator or authorized agent of same, <br />ackno),vledge 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 certit+, that I ha%e prepared this application and that tl work to be performed will be done in accordance with all SAN JOAQuIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL Nvs. <br />.-APPLICANT'S SIGNATt`RE: DATE: <br />PROPER i / Bl siN ss ONN*st:RrL OPERA IOR/ NIANAGER ❑ OTUER At THORIZED AGENT ❑ <br />IfAPPLIGI N7 is not the BILLIAG PART) proof of authorization to sigh is required Title <br />AUTHORIZATION TO RELEASE INFORNIATION: When applicable, I, the oli ner 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 />�ME <br />ACCEPTED BY; <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />$ERVICE CODE: <br />P,E; <br />Fee Amount: Ikd <br />Amount Paid % . CI -7 <br />Payment Date <br />S <br />Payment TypeS <br />Invoice # <br />Check # � <br />3 3� <br />Received By: <br />EHD 48-02-025 / 66 3 7D SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />11 <br />EO <br />Ili TO <br />,VA w <br />lines <br />