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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5',e00 <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME .� <br /> w 1 <br /> SITE ADDRESS I�><F S— j �jo�c�'l� i✓y �ti Cii 17/I � ;3C <br /> Street Number Direction Street Name :ity Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> ( <br /> 1 C) l% 0 Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �Sv LM if <br /> .� CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> 7�0 a al0 ( te(G) <br /> CITY he p STATE ZIP Q[csv/ <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 fonn. <br /> I also certify that I have prepared this application and that the work to.)e performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAT EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: O�-�!5 It <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGRA OTHER AUTHORIZED AGENTE) Alk4'(TeprT -e& <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 HEALTH 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: PAYME <br /> COMMENTS: <br /> FEB <br /> SANNVIRONMENTAUIN L <br /> HSI}{DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: % DATE: !�, r S- <br /> ASSIGNED TO: : EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: rel PIE: � C <br /> Fee Amount: 3 �C) Amount Paid '153 L( 'C-0 Payment Date <br /> Payment Type ✓ Invoice# Check# Z Z(0`7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />