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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5(Z o0 4 S I CO2 <br /> OWNER/OPERATOR _ 11 <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS �S7ZI FQ.cvJT �T7�E>;T L/1JDF_nJ 4)-7z3i�' <br /> SMaet Number rtecuon Street Name C' <br /> Zip Co e <br /> HOME Of MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE G� ZIP �S, Z <br /> I�Opt <br /> PHONE 81 EXr. APN# LAND USE APPLICATION# <br /> (2c)-)) 7371 <br /> PHONE 12 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR It SERVICE REQUESTOR 1�1 <br /> REQUESTOR M(9-,� my CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> 3 FAx <br /> HOME or MAILING ADDRESS P. O . a0X V8o ( # <br /> ?4f-,9723 <br /> CITY Lobi (. STATE `� ZIP :�)!57-7-4/ <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 1 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 D L laws. _ ey <br /> APPLICANT'S SIGNATURE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZEDAGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Titte <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it i5 available and at the Same time It Is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: T <br /> COMMENTS: <br /> /V /c CO <br /> e5cc7rc <br /> (O ilJinl J SAN JOAOUIDI UN ONPE - <br /> ENVIFtJTM '- 1 <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: P^� EMPLOYEE#: 1 DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: P I EG !t <br /> Fee Amount: Amount Paid Paymen Date �-� <br /> Payment Type I j Invoice# Check# D Rec ived By: �} �- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />