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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> FILE topl <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0c-)eo� <br /> OWNER/OPERATOR <br /> � CHECK If BELLING ADDRESS <br /> FACILITY NAME <br /> SIl E ADDRESS! d� '— j�L� ✓''. L>9t"TI�Gt�' G� i,i> <br /> ieet �" <br /> Street Number Direction St Name Ci zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number tree[Name <br /> CITY STATE Zip <br /> PHONE#1 EXT APN# LAND USE APPLICATION# <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CNECK ifBIWNGADDRESS❑ <br /> BUSINESS A E, ,, r /- PHONE# p _ Ex' <br /> HOME or AILING ADDRESS M V p ({tY'D FAX# <br /> STATE`-,mss ZIP <br /> CITY <br /> e�T <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 t 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 law <br /> APPLICANT'S SIGNATURE: ` 'f -- DATE: ( � r <br /> PROPERTY/BUSINESS OWNER OPERATOR/N'LANAGER ❑ OTHER AuTHOR17.F,D AGENT❑ <br /> If APPLICANT 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 HEALTIi 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: rR4'-Jl�_...-n/ '�' I��.'�/s7 G y � U< . <br /> COMMENTS: <br /> .ic <br /> _ SAN JOAQUIN COUN <br /> ENVIROFAENTAL <br /> i <br /> ell) <br /> �" t HEALTH DEPARTMEW <br /> l �'xck�,� +'f!EfL''^� �/��✓;';i�v/✓Gji �� :.Jilt fsr <br /> ACCEPTED BY: EMPLOYEE#: DATE: 2 / <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 1 P I E: 3 J <br /> Fee Amount: 11 2 Amount Paid l(( Z_. Payment Date <br /> Payment Type Invoice# Check# ID D (o Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117!2003 k ,1 <br />