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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> O NER/OPERATO <br /> I �1 I I CHECK If BILLING ADDRESS❑ <br /> nFACILITY DAME ' l l� <br /> SITE ADDRESS r^ L nom , J��C q5377 <br /> C Street Number Direction (�Y ,I Street Name i ZipCode <br /> HOME or//(MAILING ADDRESS (If Different from Site Address) <br /> y Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REUESTOR <br /> CHECK If BILLING ADDRESS <br /> lan n-LL- 6D <br /> B � INESS NAME / PHONE# EXT. <br /> _ <br /> HOME orAIDING ADDRESS I FAx# <br /> Vl L r -)u-4- <br /> CITY C haf <br /> I 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 <br /> laws. — <br /> APPLICANT'S SIGNATURE: +T �/ '�'' DATE: -PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ ��iS�Q/7� ��c�� cz✓� I� <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. L <br /> TYPE OF SERVICE REQUESTED: j L I'D I'Yl 1 Vz+ 1 <br /> COMMENTS: <br /> FVC <br /> y� R Q0i ?�,9 <br /> ryo�qRF r��ry <br /> ACCEPTED BY: EMPLOYEE M DATE: , <br /> ASSIGNED TO: /N /� EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE. I WE <br /> Fee Amount: I cJ•2 .OD Amount Pai /5'2 Payment Date 1 <br /> Payment Type C�� Invoice# Check# ��930�Z� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />