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SAN JOAQUIN rOUNTY ENVIRONMENTAL HEALTH T)EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GC:�'---, \ 0 <br /> OWNER/ OPERATOR <br /> C �, CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> 1 q 2- <br /> 1 <br /> Street NumberSITE ADDRESS (.3CCV0 <br /> O <br /> Direction Street Name city Zlo Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY 1 STATE\ � ZIP <br /> h�C� C� <br /> PHONE#1 E)r% APN# LAND USE APPLICATION# <br /> Q0 UL 6 -- 9 S 16 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 668 ) b - � <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADORES <br /> S <br /> P o' SBUSINESS NAME PHONE# EXT. <br /> — ((( <br /> HOME or MAILING ADDRESS FAX# <br /> CITY C STATE ZIP C <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 or <br /> 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: I U <br /> PROPERTY/BUSINESS OWNER❑ ERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT A C�A VIS <br /> If APPLICANT Is 1QSE <br /> LLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELNFORMATION: 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. j <br /> TYPE OF SERVICE REQUESTED: G J RECEIVED <br /> COMMENTS: Mg I g 2004 <br /> SAN J�{OIAOUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: (C/ DATE: v�( <br /> r <br /> ASSIGNED TO: 7 - EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 1 P I E: <br /> Fee Amount: , vVI Amount Paid $��� Payment Date <br /> Payment Type Invoice# Check# �� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />