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SAN JOAQU-, COUNTY ENVLRON-MENTAL HEAL DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> i <br /> OWNER/OPERATOR ` /r <br /> V C/ CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS Zae�e Or 6f a37 <br /> Street Number Dlrectlon Street Name zip cob <br /> HOME or MAILING ADDRESS (If Different from Site Address) ,C)_ 13e{?.5012 v-t° <br /> i <br /> Street Number NMM <br /> CITY //� u� STATIN ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> off) 7,9 , s <br /> PHONE#1 Err. BOS DISTRICT LOCATION CODE <br /> cloy) '_3 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> RECENED <br /> HOME Or MAILING ADDRESS ' NOV 0 4 20% FAX# <br /> L ( ) <br /> CITY SAN JOAQUIN COUtm STATE LP <br /> pyvlR,?NMENTAl- <br /> HFAi <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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: � DATIEy�1, <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ri <br /> If APPLICANT is not the BILLING PARTY.proof of authorization to sign is required Tirte <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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 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: ek&-n e a 74 ol, 'C SGL �/I� G�// e�C/�S /✓tom ISG 6l� e�► �, J >`p✓C <br /> �,-�,- ��a ;o✓z wi��G°Uh 7i vt u,e �vU,6P os✓eraby Te�sorv. <br /> ACCEPTED BY: v EMPLOYEE#: DATE: i <br /> ASSIGNED TO: �i Vel �� �. EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ;- P/E: <br /> Fee Amount: j Amount Paid Payment Date 11M P <br /> Payment Type Invoice# Check# Z_- Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />