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SAN JOAQLCOUNTY ENVIRONMENTAL HEALTIJEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> L) In -]d <br /> OWNER I OPERATO(t <br /> CHECK If BILLSNG AODRE55 <br /> i u F <br /> FACILITY NAME DC-- <br /> SITE <br /> omSITE ADDRESS 10kP1'1/3TN 7 aQIPD N 61A85366 <br /> Street Number Direction Street Name City Zip Cade <br /> HOME or[NAILING ADDRESS <br /> �(If Different from Site Address) y�^�77 <br /> 2�2 and pic- i."2Streel Numher Street Name <br /> CITY � STAT E f _ zip <br /> PHONE#1 Ems• APN# LAND USE/.APPLICATION# <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> f 1 <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR fir ' <br /> C! CNECKIf BILLING ADDRESS <br /> BLISINESS NAME PHONE# Ext <br /> HOME Or MAILING ADDRESS FAx# <br /> f ] <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 we or my business as identified on this form. <br /> I also certify that [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 an DERAL laws. <br /> 4 l-r 14 <br /> APPLICANT'S SIGNATURE: ' 'r DATE: r � <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAppLICANT is not theBILLINGPARTY,proof of authorization to sign is required Title <br /> I 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available an the <br /> Asame time it is <br /> provided to me or my representative. �yivp <br /> TYPE OF SERVICE REQUESTED: PIAIVI l yJ4f; <br /> COMMENTS: 042o14 <br /> SAS JOgQUt <br /> CIV V <br /> NEq 0 ggrMUNry <br /> ENT <br /> ACCEPTED BY. A /,�V)�1' t EMPLOYEE#: DATE: <br /> ASSIGNED TO: LEMPLOYEE#: DATE: r <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: 2'4 e) Amount Paid <br /> �'gL b,(D 0 Payment Date � 1k <br /> Payment Type 8 Invoice# ✓��� /.ecic# j�W c1�Z ReccAved'By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1 111 7/20 03 <br />