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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 12 <br /> OWNER/OPERATOR <br /> O ,`` CHECK If BILLING ADDRESS <br /> FACILITY NAME 1� <br /> SITE ADDRESS (,J_ <br /> 12— t Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> / 6 ( (1 AJ LA 'c- (�C t I Street Number Street Name <br /> CITY STATE ZIP <br /> IL-ti4� '-" CLd� gtS3-?j, <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> RE UESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> HOME or MAILING ADRESIS FAX# <br /> CITYSTATE ZIP <br /> JJ <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 tha work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and E L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILGING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operatoro �ocated at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or e: assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is avail t e same time it is <br /> provided to me or my representative. _ <br /> TYPE OF SERVICE REQUESTED: C-01 INTY <br /> COMMENTS SAENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: C-- 0�k'�1 L EMPLOYEE#: DATE: <br /> ASSIGNED TO: �` \- <br /> k\NS CI \ - EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: li n o 2 <br /> Fee Amount: \tea.U0 Amount Paid Payment Date V( <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />