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1 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 64�5 s4--,+ ,:- X321 <br /> OWNER/OPERATOR . - Q / <br /> M .,JD v� J /N N CHECK if BILLING ADDRESS <br /> FACILITY NAME Q ork—CIO <br /> SITE ADDRESS _ �.� , {�y M L 14 TRY ,y(v 4 S'� � (+� 7 l (. <br /> �.It ,-) lel tt lL L J <br /> St Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT77 APN# LAND USE APPLICATION# <br /> (;>0j ) 6a ►— G's/Z- <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY STATE ZIP <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 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 and FEDERAL laws. �y <br /> APPLICANT'S SIGNATURE: NN ' , SIS.. DATE: <br /> PROPERTY/BUSINESS OWNER® OPERAT /MANAGER ❑ OTHER AUTHORIZED AGENT❑ CJ�U--v <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 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: <br /> jsi- <br /> COMMENTS: <br /> ACCEPTED BY. EMPLOYEE#: DATE: <br /> ASSIGNED TO: - �i rr EMPLOYEE#: DATE: l <br /> Date Service Completed (if aicgjby completed): SERVICE C DE: P I E: 6 <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />