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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -AWNER/OPE'_IOR <br /> I'M I /� CHECK If BILLING ADDRESS <br /> CILITY NAME <br /> SITF Annorcc <br /> l 5A -eet Number ion ll� ►2- t2 <br /> trDirectStreet Name CiN Zio Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> GLTY STATE zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> cIoSCA It10 Pq -/5--23 (ins <br /> PH 2 Ext. BOS DISTRICT LOC TION CODE <br /> IPOt�r-40o I ©� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ��I p,/C/�^ CHECK If BILLING ADDRESS <br /> BUSINESS NAME �lG'Y JIIY r PHONE# EXT. <br /> 9QME or MAILING ADDRESS / 2— FAX# <br /> ,CITY 1 r� t STATE ( A 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 /> 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, STATE and FEDE L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATO I MAN G ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization f0 sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same time it IS provided to me Or <br /> my representative. c <br /> TYPE OF SERVICE REQUESTED: 5 L� C t.(,bst ,� (�It tyy� "'4ti,-A- <br /> COMMENTS: 3lif/15- <br /> � 20 <br /> pQ,v1N C0004 <br /> 0, <br /> ACCEPTED BY: f w c EMPLOYEE#: <br /> ASSIGNED T0: l "7 EMPLOYEE#: DATE: _r <br /> Date Service Completed (if already completed): SERVICE CODE: 1 5 PIE: '�(�G- <br /> Fee Arnount: Z b� Amount Paid � Payment Date Z� 1 <br /> Payment Type Invoice# Check# — 1 ' Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />