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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 4 �— <br /> y <br /> OWNER OPERATOR <br /> „�^ CHECK if BILLING ADDRESS ' <br /> FAa ani► <br /> ff <br /> U <br /> SITE ADDRESS_ <br /> I <br /> i tr et Name C?�7f od <br /> Hicing or MAILING ADDRESS ilf Different from Site Address <br /> 1 Street Number Street Name <br /> Cl tt—1 V� Lit <br /> PHONE#11 ///� EXT. APN# LAND USE APPLICATION# <br /> ( ( q31 <br /> V 6 <br /> PHONE#L EXT. BOS DISTRICT LOCATION CODE <br /> V � <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> OR <br /> r/l CHECK if BILLING ADDRESS <br /> S, ME -� PHONE.# IT, <br /> �l l' <br /> E r MAII-w ADD SSL-A) F- �j /Q FAX# <br /> CITY <S7 <br /> TATE �LZiR A <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 t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ST E L laws. <br /> APPLICANT'S SIGNATURE: DATE: I �� <br /> PROPERTY/BUSINESS OWNER 6PERATOVMANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPL/CANis not the G 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 scene time it is <br /> provided to me or my representative. r+q/1X <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: SAN�-ID4,q <br /> N <br /> CIXS �StoyA�D{1 <br /> h qi;, QU/N C <br /> NT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: r EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: O P 1 E: <br /> omel b Z <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 />