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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 7-2OWCCg� S74-2- <br /> OWNER <br /> NER/OPERATOR l��) , <br /> T l + , CHECK if BILLING ADDRES <br /> FACILITY NAME <br /> L1 CIL c.) <br /> SITE ADDRESS -?LI Ll l� , 101 '3'?'C�o <br /> Street Number 'rection Street Name Cit ode <br /> HOME or MAILING ADDRESS (if Different from Site Address) 112-0 t'i' ojt�qev <br /> Street Number Street Name <br /> CITY , STATE /1^ ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> C4 0 <br /> PHONE#2 EXT BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR t <br /> ((A!� CHECK If BILLING ADDRESS <br /> 7 l C PHONE# EXT. <br /> BUSINESS NAME i „ -) r wt l o— SS, ' <br /> HOME or MAILING ADDRESS /i �l1 U, ( � ; 1,�, J�, FAX# J <br /> CITY vv 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 a FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: IC 2 1261c <br /> PROPERTY/BUSINESS OWNER❑ OPERAT R/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT 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. A. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: vV 1Vl v U n r` � OCC �O <br /> FNi°R ?419 <br /> QCT �N CO <br /> y�FpgRN1.14 <br /> ACCEPTED BY: EMPLOYEE#: DATE: G I G^ <br /> ASSIGNED TO: �V�/`v EMPLOYEE#: DATE: l <br /> Date Service Completed (if already completed): SERVICE CODE: ( P I E: <br /> Fee Amount: , Z 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 />