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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR cou>aw !smiF 1ogt1e3TMENT-S L PCK If BILLING ADDRESS❑ <br /> FACILITY NAME h 1 <br /> SITE ADDRESS <br /> QV S~Number Direction r ry ` Straet Name Cit Zi Code <br /> HOME or MAILING APDRESS (if Different from Site Address) <br /> 4 If 60 IZOA t> <br /> :�ael47u Street Name <br /> CIIJ wA ZIP <br /> PHONE# EST. APN# C• LAND UAE APPLICATION# <br /> (925) 445- cline 2r9-090 . 25 'PA <br /> -0s- sq4 -S - <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> I 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR1 �� I EXT. <br /> ' L I CHECK If BILLING ADDRESS® <br /> BUSINESS NAME l �l PH NE# <br /> HOME or MAILING ADDRESS FAX# <br /> 00 Qct. �6 FIS) 4(U3�lO <br /> CIN TI-e CA STATE LP <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 /> also certify that I have prepared this application and that the work IDA performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY ordinance Codes,Standards,STATE ani ERAL <br /> APPLICANT'S SIGNATURE: '�� DATE: 40-0 <br /> PROPERTY/BOSINESSOWNER OPERATOR/MANAGER ❑ OTHERAC Onizu)AGENT❑ <br /> If APPL/CdNT is not the BauNc PARTY proof of authorization to sign is required Title <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 is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: S()P 5 v t,�LA-�� ', <br /> �d 9DSMfs[;aPAA%g ANO imXr r 569Th p Nfy PAYMENT <br /> RDM.t 1 �I��t�.Y �ll<j I�.t1�lE� �02 TE/Vg7��/E /114.4p ED <br /> .0,7603 laws- APR 1 0 2�Q <br /> EMPLOYEE#: DATE: MENTAL <br /> rFeeAmount: <br /> D BY: R J'B �� 3 IBIME IT <br /> TO: " EMPLOYEE#: (�D ti(S DATE: <br /> rvice Completed (if already completed): SERVICE CODE: PIE: 2603- <br /> on <br /> 6 Q <br /> '06 Amount Paid g�r , p� Payment Date <br /> t Type ,`. Invoice# Check# 2 2— L Received By: , <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 - <br />