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3ANJOAQUINCOUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property <br /> f-9 r FACILITY ID# SERVICE REQUEST# <br /> t <br /> OWNER//OPERATOR <br /> 4P0A1.50L0 <br /> s� CHECK if P.11-LING FACILITY NAME <br /> i <br /> SITE ADDRESS <br /> y <br /> reet Nu��diI I,tT" . <br /> rection eet Name <br /> HOME or MAILING ADDRESS (If Different from Site Address) c' zi Code <br /> CITY � Street Number Street Name <br /> ZIP <br /> PHONE#1 EXT. <br /> r G} { LAND USE APPLICATION# <br /> [!i` �7 <br /> PHONE#2 � Z�SZCf`rCS <br /> EXT. <br /># ( } BOS DISTRICT LOCA DN CODE <br /> REQUESTOR <br /> CONTRACTOR/ SERVICE REQUESTOR C� <br /> 3 CHECK if BILLING ADDRESS '` <br /> BUSINESS NAME <br /> HOME MAILING DDR S Z r <br /> CITY <br /> ST ZIP 7e57a 0 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, f <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 /> I also certify that I have prepared this applica ' n and that the Work to be performed will be done in accordance with all SAN JOAQUIN f <br /> COUNTY Ordinance Codes,Standards, S;kVnd FEDERAL law,,_ <br /> APPLICANT'S SIGNATURE: <br /> l — � DATE: o �� V <br /> PROPERTY/BUSINESS OWNERE] OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> Girl J t. <br /> Ifis not the BILLINGP,9K7y proof of authorization to sign is required Trite <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: LL <br /> COMMENTS: PAYMENT <br /> 2007 <br /> SAN JOAQ UIN �A <br /> ENV1R0 <br /> ACCEPTED BY: IiEALTt,DEPARTMENT <br /> d �C L1+�1.C s e EMPLOYEE#: Q� DATE: Il 'elo 7 - <br /> ASSIGNED 7p: �£� <br /> EMPLOYEE#: 3(r f DATE: C10 7 <br /> Date Service Completed (if already completed): T° <br /> SERVICE CODE: ,Z.� P!E: <br /> Fee Amount Amount Paid <br /> C? <br /> � `��. Q7C) payment Datej ( � <br /> Payment Type Invoice# Check# <br /> (op p Received By: <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 SR FQFt11A:{Golderf'Rod) s <br />