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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> /490✓/G Tis-�.9T/I cry' V r j r t�I I <br /> OWNER/OPERATOR <br /> "(5•evz �� ���/^/��^tel p v� CHECK If BILLING ADDRESS <br /> FACILITY NAMEG��iO/v <br /> SITEADDRESS n x 2 N <br /> f. r <br /> Sir—Nu mber D ton Street a City ZIP Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> l/�✓r��✓o�^�•-✓ r9r CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> HOME Or MAILING ADDRESS FAX# <br /> ( ) <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 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 [have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY OrdiHance Codes,Sfatidar'ds,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: � —"7 DATE: <br /> PROPERTY/BusmESs OWNER 1:1 �' OPERATOR/DIANACER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is trot the BILLING PARTY,proof of aHtltorizatlott 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 DEPARTNENT as soon as it is available and at the same time it is <br /> provided to me or my representative. /p <br /> TYPE OF SERVICE REQUESTED: EIV <br /> COMMENTS: NOv 08 <br /> 20 <br /> H EftV CAu <br /> EAiN O& <br /> b� <br /> ACCEPTED BY: e EMPLOYEE#: &2DATE: J / <br /> ASSIGNED TO: L 4 EMPLOYEE#: 'C DATE: ( <br /> Date Service Completed (if already comple d): SERVICE CODE: P/ <br /> Fee Amount: Amount Paid 30 q Payment Date <br /> Payment Type S� InInvoic/e-# Check# Received By: <br /> rA <br /> EHD 48-02-025J w SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />