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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> R <br /> es c0C(- l� <br /> OWNER I OPERATOR CHECK If BILLING ADDRESS <br /> L C TO[ 67L, /I'I <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Ity <br /> r� S ZZ p <br /> Street Number DlrectlonE � fel�(� Street Name UN=� 1 C� Z( Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Stree Name <br /> CITY STATE ZIP <br /> # <br /> PHONE#I ExT. 7coj <br /> PN LAND USE APPLICATION# <br /> ( ) , 6d -0 -- <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> ( ) azo <br /> CONTRACTOR/ SERVICE REQUESTOR u� <br /> REQUESTOR S4 RI 'V C Jtn'L CT w CHECKifBILLINGADDRESSO <br /> BUSINESS NAME PHONE# ExT' <br /> S Co,tiSr2ctcT SEr T$c ` I(,,, ) V 7 9-ZYS <br /> HOME or MAILING ADDRESS FAX# <br /> OT77 St , -e 2 co ( ) <br /> CITY STATE ZIP 8.Z �j <br /> �q'L iZ/`tn'f CJJ t� CA ��O Q <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 DEPAR,rmEyr 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 /> COUN rl'Ordinance Codes,Standards,STATE and FED laws. <br /> APPLICANT'S SIGNATURE: DATE: ©y�0 Z/ �J <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ f2TZJGrGji t— <br /> IjAPPLIC,fNT is 1101 the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 Cowry 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: co/\. <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: / P/E: L <br /> Fee Amount: Amount Paid !S� (�� Payment Date <br /> Payment Type Invoice# Check# � 6 5-- Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />