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SAN JOAQUriV COUNTY ENVIRONMENTAL HEALIWOEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 60 o n 163 <br /> OWNER/OPERATOR —y= 0,V ( CHECK If BILLING ADDRESS <br /> FACILITY NAME CL ET ' 14 <br /> SITE ADDRESS / p / �� 9S 3 <br /> Street Number 1 etl 1 1 <br /> Cl <br /> HOME or MAILING ADDRESS (If Different from Site Address) D h,-/ <br /> (� VU^""street NumberStroet Name <br /> CITY w�J STATE ZIP 411 <br /> �. <br /> PHONE#1 Ems' APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS❑ <br /> i <br /> BUSINESS NAME PHONE# EXT <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP - <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or autborized 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 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.,�/�j �( // 2 <br /> 9/IAPPLICANT'S SIGNATURE: ���L'`2 LGtw—) V.Cl/ DATE: C)/ — 0 /J <br /> PROPERTY/BUSINESS OWNED OPERA ER ❑ OTHER AUTHORIZED AGENT 13 <br /> IJAPPLICANT 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 HEALTH DEPARTMENT as soon as it is available and at thti„same time it is <br /> provided to me or my representative. N'Q <br /> TYPE of SERVICE REQUESTED: _ C V <br /> COMMENTS: YL SqN 00 O <br /> N'f�.l Oln!/✓ETH"/1� p� HFq�y9�N1p�3 <br /> X� q��rq <br /> lv' <br /> Np <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: ,114 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed):— <br /> SERVICECODE; P/E: <br /> Fee Amount: �-�; " Amount Paid C` Payment Date ? _ <br /> Payment Type Invoice# Check# Received By: - <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />