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SAN JOAQ COUNTY ENVIRONMENTAL HEAL' DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> L w �= CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS � <br /> St/reef Number Direction / / Street Name Cit / Zl Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHON #1 Ex-r. APN# LAND USE APPLICATION# <br /> (05� 1 q 22 y q � 3 �, d�' 0,0t, <br /> PHONE#2 EXT. BOS DISTRICT LOC�ION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> n/ � CHECK If BILLING ADDRESS <br /> }� P 51 - S Z 1 EXT. <br /> BUSINESS NAME �J„ / ,����4�v !✓ 2 <br /> HOME Or MAILING ADDRESS FAX# <br /> S i (5 Io 1 �� <br /> CITYr 6-Al <br /> 0,/v <br /> ,N r 1171 <br /> $TATE 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 ENvIRONNmNTAL 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,ST,AJE and FEDERAL laws. �j <br /> APPLICANT'S SIGNATURE: (Z4 �t�Jt� DATE: /—/%7 / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT��t AA// &� Iliy Q- <br /> IfAPPLICANT is not the BiLuNG 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 time it is <br /> provided to me or my representative. VA <br /> TYPE OF SERVICE REQUESTED: is UV, <br /> COMMENTS: l�f'l 01A.�-5 i✓i^ d'1__ L_ �15�1� ���'l.✓ �!� 1 , O <br /> HFA�NVIR0 trVCO <br /> THof l`p rNrY <br /> ACCEPTED BY: C=t ' EMPLOYEE#: DATE: l <br /> ASSIGNED TO: lV y 5 Vv�l EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE:3 P 1 E: <br /> Fee Amount: Amount Pai&L3 75: -D Payment Date <br /> Payment Type Z Invoice# Check# Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />