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SAN JOAQUL. —OUNTY ENVIRONMENTAL HEALTH IIEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ('a e r 1 n q 5Q 0J9A ';9 S <br /> WNER/OPE TO <br /> "e <br /> ���2 ;o <br /> C—q <br /> �n, CHECK If BILLING ADDRESSLl FACGw �:( <br /> ey�ll ' I <br /> SITE ADDRESS 1/ <br /> :�yy a Street Number Direction n(r 0 treat ame / Seo ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) v <br /> 3c)57 Street Number Street Name MI <br /> CITY_ <br /> S O r f / STATE ZIP 52667 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> c* �2 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> L 1/ CHECK If BILLING ADDRESSE), <br /> BUSINESS NAMI?/ PHONE# EXT. <br /> 1,2 ( ,,-/ Sao -%0 ,12 <br /> HOME or MAILING ADDRESS FAX# <br /> 3051 6S t-11'elIg A <br /> CITY S�&Cb*;-) <br /> b ;-) STATE ( ,1 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, S TE d F„DEKA I NS. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ O RATOR/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, 1, 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. ' p <br /> TYPE OF SERVICE REQUESTED: �JA CDV" , l-J <br /> COMMENTS: <br /> �DV <br /> sqNJOA <br /> 2 2D19 <br /> FAlv/& IN <br /> ykCTN�Ep F,yTA�N�y <br /> ACCEPTED BY: Y l V v`� t7 EMPLOYEE#: DATE: —1 — /ll <br /> ASSIGNED TO: _ SGw`' ��C� EMPLOYEE#: DATE: 1 <br /> Date Service Completed (if already completed): SERVICE CODE: c1 .. PIE: N006 <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# heck# Received B <br /> Y C <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />