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SAN JOAQSCOUNTY ENVIRONMENTAL HEALTOEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Marheue kEsiaura' t 4 L(o 5�-00 V-T�-) 9 <br /> OWNER/OPERATOR <br /> )' CHECK If BILLING ADDRESS <br /> FACILITY NAME � <br /> Q e w5 <br /> SITE ADDRESS DOS /p�. Q I n Q Q n <br /> Street Number Direction Street Name) City Zip Code <br /> HOME �pMAI INGNRESS (If Different from Site Address) <br /> vStreet Number Street Name <br /> CITY�� � �+ C 7 SATE �IP <br /> P NE#l1 J ExT. APN# LAND USE APPLICATION# <br /> �> <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> u CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> i <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <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 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, ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE DATE: 7 ���3 <br /> PROPERTY/BUSINESS OWNER67— <br /> OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLTNG 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: <br /> COMMENTS: <br /> JUL u s ?03 <br /> SAN JOACIUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: -_ EMPLOYEE#: DATE: / <br /> ASSIGNED TO: J^ EMPLOYEE#: DATE: <br /> Date Service Completed If already completed): SERVICE CODE: ^Z_ P/E: v <br /> Fee Amount: ° Amount Paid �i Payment Date 7 f <br /> Payment Type Invoice# Check# Received B � <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />