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l0 D ► <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �c-V bv� Gaw Sgt <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS1/ I IN I I �"��T —T'� <br /> 1 ✓ �O Street Number DlirNection Street Name 1 Ci Zip Code <br /> HOME 0 (If Different from Site Address) <br /> Street Number Street Name <br /> CITYN $TATE ZIP <br /> � I Y�—lC) <br /> PHONE#1 IV EXT. APN# LAND USE APPLICATION# <br /> (5�25) -ZlzA, CY20 o <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> SERVICE REQUESTOR <br /> REQUESTOR <br /> n CHECK if BILLING ADDRESS <br /> BUSINESS NAMEI �\ �t� \ PHONE# EXT, <br /> V:RWSJ V o ` CoO <br /> MAILING ADDRESS � WlS✓ (?0-7) <br /> CITY <br /> STATE /'A ZIP <br /> BILLING ACKNOFW—L11E1D`+1GEMENT: 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,Standar ,STATE and FEDER L laws. <br /> APPLICANT'S SIGNATURE: DATE: 1- 131 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGE ❑ OTHER AUTIIORIZED AGENT JQ IV <br /> /f 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 <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 tipe it is <br /> provided to me or my representative. c ��5 �/ (7( � �,.�-[�[[s� 0 <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> CN�" N.1�PQU\MENjPt" T <br /> G1-1EP TH�PPRSME <br /> ACCEPTED BY: e'q EMPLOYEE#: DATE: /2 <br /> ASSIGNED TO: EMPLOYEE#: I&M <br /> DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �1 P/E: / <br /> Fee Amount: Amount Paid is a !. -D I Payment Date a 13 D <br /> Payment Type Invoice# Check#! ! Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />