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SAN JOAQ COUNTY ENVIRONMENTAL HEAL )EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property _ FACILITY ID# SERVICE REQUEST# <br /> ODD k <br /> -OWNER/OPERATOR ' � <br /> CHECK ifBILLING ADDREIS <br /> S 0 <br /> ACIUTY NAME � � L�J �B •�^ <br /> SITE ADDRESS b N uu.<�-�I'(' <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME <br /> -olr MAILING ADDRESS (If Di event om Site Address) <br /> t J t l T " Street Number Street Name <br /> C STATE ZIP <br /> CITY ►� 7C S C=Pf' ,5 <br /> PHONE#I EXT APN# LAND USE APPLICATION# <br /> (GoS 7 i3ok <br /> PHONE#2 E BOS DISTRICT LOCATION CODE <br /> 54 r7 CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> r CHECK If BILLING ADDRESS <br /> v <br /> BUSINESS NAME PHONE# EXT. <br /> `70 -5G <br /> HOME or MAILING ADDRESS FAX# <br /> ^ I ( ) <br /> CITY STATE 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 ENVIRONNIENTAL 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 Ordin ce Codes,Standards,STAT s.. <br /> APPL NT'S SIGNATURE: 'E: J I O <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER El OTHER AUTHORIZED AGENT 13 -�-��3 <br /> If 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 time it is <br /> provided to me or my representative. //�� <br /> TYPE OF SERVICE REQUESTED: %Okk a �-p lr�� pW�� <br /> Eta <br /> COMMENTS: t�•`7'C�I•J��vlr S C'WIII,j .`7`a4A djV4� - <br /> Nov 2 1z� <br /> SAN JOAOUIN COUNTY <br /> FN\jI"0MF-N rAL <br /> HEALTH DEPAIRTMENT <br /> ACCEPTED BY: r EMPLOYEE#: DATE: <br /> ASSIGNED TO: t EMPLOYEE#: DATE: 1 <br /> Date Service Completed (if already completed): SERVICE CODE: o b l P I E: ( b <br /> Fee Amount: t Z S pJ Amount Paid Payment Date f <br /> Payment Type Invoice# Check# — Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />