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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> aNAM <br /> iness or Property FACILITY ID# SERVICE REQUEST# <br /> Dry �' fb'79�� <br /> OWNER/OPERATOR �NyfU 4 . CHECKIfBILUNG ADDRESSO <br /> S G ��G' �sero.tNumbar � aLING ADDRESS (N Dkterent Om Ske Address) �ffNdtt Name <br /> STA ZI <br /> Exr. APN# <br /> .-. / 6 2 L-1 �7 LAND USE APPLICATION# <br /> PHONE#2 l/j_ Exr. L SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REOUESTOR—ten y�Q' <br /> Vl/ t`t CHECK k BILLING ADDRESS <br /> BUSINESS NAME <br /> C P E# /G <br /> Ho or MAIL( A�Dy,RESS qFAX# �/ <br /> Clrr v-r_ STATE/ ZIP 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 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,STA and FEDERAL laws. <br /> APPLICANT'S SIGNATURE o (ark — DATE: <br /> e// <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLICAVT is not the BILL/NG PAj? proof of authorization to sign is required 11 Tis <br /> AO <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 <br /> g amental/site assessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is avairl/10 <br /> provided to me or my representative. etime it is 1 <br /> TYPE OF SERVICE REQUESTED: CC LL OV-) y 1I/E� <br /> COMMENTS: <br /> ?018 <br /> Cncln�e c� ���� SgNVOgQUIiVCCUN <br /> HEACTii pEPgR MEnn <br /> ACCEPTED BY: ���'\ EMPLOYEE#: DATE: l� <br /> ASSIGNED TO: <br /> k <br /> ``yt, EMPLOYEE#: DATE: <br /> Date Service Completed (If alread completed): SERVICE CODE: 616 / PIE: U . <br /> c-, G <br /> Fee Amount: 1e-,2vD Amount Paid S2.OD Payment Date <br /> Payment Type ��/ Invoice# C heck# e� <br /> 24D 60 Received By: <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br /> SCa44 — <br />