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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 <br /> a- rr � I IsM CHECK if BILLING ADDRESS <br /> o6vlv. e <br /> FACILITY NAME I <br /> t "c1I ""ZC.— <br /> SITE ADDRESS N;te 13 <br /> 5 Street Number Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) )3 t ZE, Te i,es.5 E e S t <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( yts ) �V 7- �2 t <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (70 7) 365 - 00-70 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <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 or <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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: Z-Z - o-7 <br /> PROPERTY/BUSINESS OWNER❑ OPE TOR/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 90t btivsite assessment <br /> 3a6i <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is avai "N�R"ame time it is <br /> provided to me or my representative. `, <br /> TYPE OF SERVICE REQUESTED: n FEB <br /> COMMENTS: vOUIN COU <br /> �b <br /> SA 0NV RONME"TM w <br /> N,EpLTN DEPAR <br /> ACCEPTED BY. EMPLOYEE#: DATE: a <br /> ASSIGNED TO. J EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE: C} <br /> Fee Amount: Amount Paid Payment Dat <br /> Payment Type VCInvoice# Check# Received By: <br /> EHD 48-02-025 CQI�GG/�-'"`• t�'O 1� !o SR FARM(Golden`'Rod) ` <br /> REVISED 11/17/2003 <br />