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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME �1 V R CA, <br /> SITE ADDRESS l ^ <br /> Street Number Direction Street N Cit Zi Code <br /> HOME or�MAILING ADDRESS (If Different from Site Address) t , <br /> 1 f VA Street Number —`5C Street Namel � <br /> CITY 5�C K�� STATE ZJV, q O <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# L 1 <br /> PHONE EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORr I ` \j <br /> - ^ CHECK If BILLING ADDRESS <br /> S <br /> �\—`{/ l��VA 1 \ \` V l_\ PHONE# .� EXT. <br /> BUSINESS NAME �C�0V�C\ � f1 q� C) tZUCt 1�3� �S <br /> HOME or MAILING ADDRESS �j FAx# <br /> CITY /� � STATE ZIP Dq <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, TATE and FEDERAL laws. q <br /> APPLICANT'S SIGNATURE• �C�y` `- DATE: ' 1 <br /> PROPERTY/BUSINESS OWNER�4�Yr"-/ OPERATOR/MANAGER ❑ OTIIER AUTHORIZED AGENT❑ <br /> If APPL/CANT 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 environmentaA�/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at 'me it is <br /> provided to me or my representative. • <br /> TYPE OF SERVICE REQUESTED: PQ <br /> COMMENTS: $�✓ O 201.9 <br /> h FRQ�tHc J <br /> E9CTy�� �H7Y <br /> HT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: `�.oq Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 iU��� —1 J p SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />