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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0(� `'I <br /> OWNER/OPERATOR <br /> A � CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> ITE ADDRESS _ C-1}— l <br /> ,�' Street Number Di on StreetYJ`arde Q-1 Ci � Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1Ex7. APN# LAND USE APPLICATION# <br /> (A ) 02--Z819 2-281 <br /> PHONE#T EXT. BCIS DISTRICT LOCATION CODE <br /> 6-2D I---5-f-�s 3 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �2 i - �— �lV- q CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY t� 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, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 2 1 <br /> PROPERTY]BUSINESS OWNEW OPERATOR ANAGER ❑ 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 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 provided t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: e, <br /> COMMENTS: ivy <br /> 0, Q�i 9 �8 <br /> ��ti FA�yFNO <br /> ACCEPTED BY: mooevlo EMPLOYEE#: DATE: n� N <br /> ASSIGNED TO: a n EMPLOYEE#: DATE: v f�✓iO�� <br /> Date Service Completed (if already completed): SERVICE CODE: �� P/E: 1 D <br /> Fee Amount: t� S Amount Paid(p �D Payment Date <br /> Payment Type Invoice# Check# 7! � 5� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />