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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> T pe of Business or roperty FACILITY ID# SERVICE REQUEST# <br /> M SDC <br /> O ER/ \PERATOR 1 , CHECK if BILLING ADDRESS <br /> =tnG <br /> FACILITY NAME <br /> SITE ADDRESS <br /> St—rest Number Direction Street Name C ity Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) M66 S(�3 n eve / <br /> Street Number Street Name <br /> CITYlava 1 STATE ZIP <br /> PHONE#t a ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) 7 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ` \ C—, <br /> n A C CHECK if BILLING ADDRESS <br /> BUSINESS NAME K/f,� PHnuc It EXT. <br /> H ME or MAILING ADDRESS FAX# <br /> Pink O ( ) <br /> CITY 1 ` 'onA` STATE ZIP <br /> BILLING ACKNONVLEDGEINIENT: I. the undersigned property or business o%ner, operator or authorized agent of same. <br /> ackno%%ledge that all site and or project specific ENVIRONMEN"IAL HEALTH DEPARTMENT hourly charges associated %Kith this project <br /> or activity%N ill be billed to me or my business as identified on this form. <br /> also certifj that I have prepared this a plication and that the work to be performed will be done in accordance %%ith all SAN JOAQUIN <br /> COUNTti" Ordinance Codes.Standcn•ds . A-ri:and FE U. arcs. <br /> APPLICANT'S SIGNATURE: D.\TE: D1 D7 <br /> PROPERIN/BI'SINESSONNER❑ OPFRA I OR/MANAGER ❑ OTIIER U"1"IIORIZEDAGF.NT <br /> IfAPPLICA.VT is not the Bu.i-m;PART).proof of authorization to siKu is required Title--j <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable. 1, 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 COI INTI, ENVIRONMENTAL HEAL-I'll DPPARTMt?N'I 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: <br /> COMMENTS: <br /> ✓4*o� �'F® <br /> V F IIO 1 <br /> LIZ Z,MF�o�o�9 <br /> Epi NTq NAY <br /> ACCEPTED BY: C V-AON L EMPLOYEE#: DATE: NT <br /> ASSIGNED TO: T EMPLOYEE#: DATE: <br /> Date Service Completed (if already co pleted): SERVICE CODE: Off ' PIE: <br /> Fee Amount: *5 1�2 Amount Pai S OD Payment Date 7 <br /> Payment Type ex-E�L Invoice# C� ck# gG393(G Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />