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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ OPERATOR rVi <br /> CHECK if BILLING ADDRESS 141 <br /> FACILITY NAME QU 610;'>YO\ 2--jA-4 <br /> SITE ADDRESS I� CA ST- )/ T11 S-F —)-VIA <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) �1A0 L/ A <br /> 5 A-"�C-- I?-70 f K�L�" Street Number Street Name <br /> CITY t C- 7 STATE 11�3 <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> (Z.0y ) 46 - LA t1 C) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> c r4 i Crt `T d CHECK if BILLING ADDRESS <br /> BUSINESS NAME cJ ,p �J PHONE# EXT. <br /> f V yv jam} /3 I !3 r� Z i'� ' (Z vI ) 3`' l t� <br /> HOME or MAILING ADDRESS FAx# <br /> CITY ' L L _ 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 ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> 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 E d FEDE aws. <br /> APPLICANT'S SIGNATURE: DATE: � �r /7 —db/ <br /> PROPERTY/BUSINESS OWNER R— OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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: ( w+V <br /> COMMENTS: R� <br /> Qu�N°OUN� <br /> SAEN�IRONME�MEW <br /> HEALTH DEPP <br /> ACCEPTED BY: EMPLOYEE#: ?Al DATE: <br /> ASSIGNED TO: EMPLOYEE#: All I J!1 v DATE: ' <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: .a'1/ Cfb Amount Paid$tnn c( Payment Date ( f <br /> Payment Type Gi�" Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />