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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> N u T4/ /u) -�Sf <br /> OWNER PERATOR <br /> r <br /> U, v CHECK If BILLING ADDRESS Er <br /> FACILITY NAM'T Q r( S `/ T— <br /> SITE ADDRESS /I.G- IpT"U`� <br /> Street Number Direction IJ L)pN)A Street Name J Ci Zi Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 XT APN# LAND USE APPLICATION# <br /> ( ) <br /> 9lca-, <br /> PHONE#Z -13.1 -113 <br /> BOIS DISTRICT LOCATION CODE <br /> t ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <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 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, Standa =andWS. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER --.O ERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> /f APPLICANT iFnot 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same time It Is provide �me or <br /> my representative. I� <br /> TYPE OF SERVICE REQUESTED: Nr <br /> COMMENTS: <br /> yNyR9C/Q-��� f ?� <br /> ea(Ty FpM�cOr' <br /> ACCEPTED BY: t'r EMPLOYEE M �G� / DATE: <br /> ASSIGNED TO: I UUEMPLOYEE#: '2 �( DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: V P/E: <br /> Fee Amount: / �D I, Amount Paid )S2 Payment Date c" <br /> Payment Type1( ,(, Invoice# Check# P34 Received By: <br /> EHD 48-02-025 v•y SR FORM(Golden Rod) <br /> 07/17/08 <br />