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SAN JOAQUIN _JUNTY ENVIRONMENTAL HEALTH _.'ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> fond To\\Q1 v)g`U- .\ <br /> OWNER/OPERATOR- <br /> A1 CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number I DirectionStreet Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) '23,1 <br /> Street Number Street Name <br /> CITY � rl V� u� STATE �� ZIP <br /> PHONE#1 1A E-T. APN# LAND USE APPLICATION# <br /> (2cq) (p �2 1 !�-1('0 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 1 �\ \l Ck V1-o CHECK if BILLING ADDRESS <br /> BUSINESS NAME t� PHONE# ExT' <br /> tR\2- - <br /> HOME or MAILING ADDRESS 23 L V O U �x Ave FAX# <br /> CITY 1 $TATE ZIP <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 application and that t e work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST E and FEDERA laws. <br /> APPLICANT'S SIGNATURE: DATE: 0\ - G Z02,0 <br /> PROPERTY/BUSINESS OWNED OPERATO /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, 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 envi��vCtwtn`ental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availablCz4f�l> ame time it is <br /> provided to me or my representative. c _ T <br /> TYPE OF SERVICE REQUESTED: JdAi '4J <br /> COMMENTS: 2020?0 <br /> ENVt QU�N <br /> H�rtioZ�/o�"Y <br /> NT <br /> ACCEPTED BY: C G \ � EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE: \1 n O 1 <br /> Fee Amount: Amount Paid -- _� �---° Payment Date <br /> Payment Type r; �; Invoice# Cbee�r 7 �r� - �t� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />