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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> r ,'�C)OL <br /> OWNEROPERATOR CHECK If BILLING ADDRESS❑ <br /> Rau M <br /> SrTE ADDREQSS ^ !^7/9' 91 j�? <br /> / V OSlreet Number Direction L r lName Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> ToStreet Number Street Name <br /> CINI STATE ZIP111� �7 <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# / <br /> Grp - OJFD0 . <br /> PHONE#2 ExT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /� Com' CHECK if BILLING ADDRESS® <br /> L <br /> ' <br /> BUSINESS NAME C PHONE# 7_ p� 0 <br /> HOMED rA�NG SSJ 7� 1�# )2•L 7— 3 ` O�, <br /> CITY X II C STATE ZIP 3 <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 ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST TE and F DERAL la <br /> APPLICANT'S SIGNATURE: DATE: 'l <br /> PROPERTY/BUSINESS OWNER El OP TOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLICANT is not the BH1MGPARTP 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. p <br /> TYPE OF SERVICE REQUESTED: LJI V C�/ NT <br /> COMMENTS: SAN mut 16?0p8 <br /> H�?-fy, 0 /NCOU (1 <br /> hOEpAR MFNI <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M 7 2Z DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: Z <br /> Fee Amount: Amount Pald I t Q O Payment Date t lob g <br /> Payment Type f invoice# Check# 3$ O Received By: <br /> SFt �QRMfvii(��,`bli}Cn'Fiod) <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />