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SAN JOAQU!I�h-COUNTY ENVIRONMENTAL HEAL7DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY 10# SERVICE REQUEST# <br /> e000 <br /> OWNER I OPERATOR �Q p}�O CHECK if BILLING ADDRESS® <br /> FACILITY NAME <br /> SITE ADDRESS p��rtMPO �S Z-2-O <br /> Street Number Direction eet Nam Ci Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) Co ZD L4 E• 1AJt}{Z.t'J" Lt'i . <br /> Stroet Number Street Name <br /> CITY LO STATE C_p,, ZIP <br /> PHONE#i Exr• APN# LAND USE APPLICATION# <br /> 080 ooh -310 - to <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR � CHECK if BILLING ADDRESS 0 <br /> BusiNESS NAMEPHONE# - EXT.u\fIr vNY- coo <br /> HOME or MAILING ADDRESS #r ;TT FAX <br /> o W o (2o°u 3 `05W � <br /> CITY Ob STATE C_^ ZIP oI S 7-�D <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 4 <br /> 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, Iv and FEDERA aws. / <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR I MANAGER 0 OTuFR AUTHORIzED AGEr iT❑ <br /> If APPLICANT is not the BILLTNG PARTY proof of authorization to sig►s 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 enviToninental/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: R �I � SV 2tCE r �U i�StlR�I�E CDjNT1�Wt1 N PrT1O� Gz EPpQT <br /> COMMENTS: <br /> RECEIVED <br /> MAR � 2 2� <br /> tO <br /> SAN JOAQUHEco <br /> AC7T{ApNME AL TY <br /> 711!'19 <br /> ACCEPTED BY: ��C(f,�;9 EMPLOYEE#: 03 Z4 DATE: r ( d <br /> ASSIGNED TO: �.(� EMPLOYEE#: �" [F DATE: <br /> Date Service Completed (if already completed): Si RvICE CODE: [S P!E:Z(p <br /> Fee Amount: Z3 p,U0 Amount Paid Payment Date 3 /a <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SIR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />