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t <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -3 PAM <br /> 6 �n <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS E] <br /> FACILITY NAME Comer <br /> SITE ADDRESS 0 waec S 1 y C q�20-1 <br /> Street Number Direction Street Name \� CityD Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 0 "c DISTRICT LOCATION CODE <br /> ( ) <br /> ;STOR <br /> REQUESTOR — � ��lYr'PI— �dse�J� CHECK if BILLING ADDRESSO <br /> BUSINESS NAME `V\sQ PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> gal 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 <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. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED 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 enviromnental/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: ` A <br /> COMMENTS: \� <br /> Se Nti C Co N v YY\� p ��Se eCT G Y\ <br /> -te�. Olo�ta%�•1��'" \ S5 G E9 D Nc,���c�- a� �es,c����� (�' e 0� <br /> k'CD �cxcv �ZYhe- b,r\ <br /> ACCEPTED BY: kEMPLOYEE#: O 0o DATE: <br /> ASSIGNED TO: Ma w EMPLOYEE#: Cedc>O DATE'.- <br /> Date <br /> ATEYDate Service Completed (if already completed): (Cr-L, t—i3 SERVICE CODE: syn ` PIE: `47 4 0 <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />