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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 1 OPERATOR <br /> (-L4N 1T� ]3�Y 1-{LJ�P/IGS CHECK If sILL3NGAPDREss❑ <br /> FAuL ry NAME <br /> SITE ADDRESS /011V 41157ZI Z <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) l�Z3p Dpv G AS j3 wD. <br /> Street Number Street Name <br /> CITY STATE G� ZIP 757 r <br /> Ezr. APN# LAND USE APPLICATION>x P"CIME$1 <br /> �! <br /> tqr� ) 9100 - l�la� DBS-D70- 3� �R -a -zea z� �P (Q) <br /> PNONE#z <br /> EXT. SOS DISTRICT LOCAnoNQooE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR y� CHECK If BILLING ADDRESS ~� <br /> BUSINESS NAMtEPHONE# EXT. .� <br /> PIL&orf UrLP� / <br /> 33 <br /> H.0 ME Or MAILING ADDRESS FAX# <br /> f? 0- l3oX 2-1 90 <br /> CITY �00 ! STATE C+4 Zip 'f ti ' <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 r{" <br /> or activity will be billed to me or my business as identified on this form. <br /> RI <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,STATE a EDERAL laws. / <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <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 environmentaUsite 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. N T <br /> COMMEWS: EIVEU <br /> tt 11 20x7 <br /> �! FI1a <br /> SAN 301\QU1t4 00 AL <br /> ENVIRON AFtTM <br /> AGCEPTEO BY: EMPLOYEE#: -�3 r/� DATE: L O <br /> ASSIGNED TO: Al ` EMPLOYEE#: �j ++[�J� (� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE:f 3 5 PIE: �3 <br /> Fee Amount: O DO Amount Paid Grv, O L) Payment Date If o� <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />