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SAN JOAQUIN —JUNTY ENVIRONMENTAL HEALTH . :ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1=ccD -' 2VC1C-- R00$ l 3a0 <br /> OWNER/OPERATOR <br /> hA S ( /"� L/ CHECK if BILLING ADDRESS E] <br /> FACILITY NAME f ^N D 0�OV�- �L Q m n `TI T/ <br /> SITE ADDRESS '� -� �� <br /> i O� n 'I4W7"GSL ��t � <br /> Street Number Direction Street-Name cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> JJ Street Number �+� Street Name <br /> CITY <br /> n L STATE /� ZIP <br /> C <br /> 5 V -KI K c k 7 N <br /> PHONE#1 EXT* APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> K CHECK If BILLING ADDRESS <br /> BUSINESS NAME LTJ JJ 1 \ PHONE# EXT. <br /> Ct t'1 c'(0 o Y' I <br /> HOME or MAILING ADDRESS FAX# <br /> CITY S+OG K STATE C' !� ZIP ! 5 �I /., <br /> 0 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agentofsame, <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 /> 1 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: vilDATE: <br /> PROPERTY/BUSINESS OWNER P R/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT 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 environmellf' sessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and t e is <br /> provided to me or my representative. / / ��[[ <br /> ��6wo <br /> TYPE OF SERVICE REQUESTED: O c d y e-A j C l e -Vh S' e C�i ✓l ee w,''',UlrT ' <br /> COMMENTS: �Y JOAQUIN culy <br /> CO <br /> N �0�MSE NT y <br /> Nr <br /> AL <br /> ACCEPTED BY: n J�a EMPLOYEE#: DATE: <br /> ASSIGNED TO: M �l O( r SC h u fZ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �� P I E: 1003 <br /> Fee Amount: 5.2 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 />