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SAN JOAQ COUNTY ENVIRONMENTAL HEALT YEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> �w WSIUL <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME ` In 1 _c�l 54 <br /> 1 W)t , ` v <br /> \ q <br /> SITE ADDRESS 1 J� 3 C��`1 n ' �� S�is�tJ �SZ� <br /> Street Number Directio treat Name CI Zi Code <br /> HOME or MAILING {ADDRESS <br /> (If Different from Site Address) <br /> �i 1—L- / C' U'.)1"-y Street Number Street Name <br /> CITY STATE ZIP_ _ <br /> CF\ <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR O CAY CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAMEPHONE# EXT. <br /> t1 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY m T 1�1 r ?7 STATE ZIP c <br /> UA <br /> BILLING ACKNOWLEDGEMENT: 1, 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 applica ori and that the t e per ed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAT and FEDERAL I <br /> APPLICANT'S SIGNATURE: DATE: �����' -Z� <br /> PROPERTY/BUSINESS OWNER❑ TOR/4AXNAGE OTHERT ORIZED AGENT❑ <br /> /f APPLICANT is not the BILLING PARTY proo of authorization O 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 1: flame time it is <br /> provided to me or my representative. f,— )e <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: ry <br /> S�Jo <br /> Fly QU/ <br /> Ham`"t oEpgR "n <br /> FiyT <br /> ACCEPTED BY: M b AQ' o EMPLOYEE#: DATE' S, <br /> ASSIGNED TO: � EMPLOYEE#: DATE: J <br /> Date Service Completed (if already completed): SERVICE CODE: ` PIE: <br /> Fee Amount: Amount Pai f/S� �� Payment Date /5 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />