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SAN JOAQL —'OUNTV ENVIRONMENTAL HEALTi sPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S,Q (Da91-1-WS <br /> OWN /OPERATOR <br /> 0 �� ,/a ?Z � J Q / CHECK if BILLING ADDRESS <br /> FACILITY NAME / / J <br /> SITE ADDRESS % A <br /> ,l� r 1�,,,�)— 11 n <br /> Street NNuumber Direction 1 t„ l V' Street Name Clt Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 2 / riy 7 Uf Street Number rp T Street Name <br /> CITY /0 k /0J $_ P �, G <br /> 7 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> rHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR^Ian 4(f�� <br /> CHECK If BILLING ADDRESS <br /> ��� e <br /> BUSINESS NAME J PH ` G EXT. <br /> d r �J <br /> ME or MAILING ADDRESS FAX# <br /> JO9 ) <br /> CITY IG, // C STATE CT�� ZIP <br /> BILLING ACfKGNOWLEDGEMENT: 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 /> 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 an FEDERAL laws. <br /> APPLICANT'S SIGNATURE: / DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPER R ANAGER ❑ OTHER AUTHORIZED AGENT 11If APPLICANT is not the BIL ING PARTY proof Of authorization t0 sign is required Title <br /> AUTHORIZATION TO RELEASE 1 FORMATION: 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. A <br /> TYPE OF SERVICE REQUESTED: V--\)3 G.t �j C V1t(� \�1L, Q C 1�i ieceWo <br /> COMMENTS: FFp <br /> CDD 192020 <br /> 114KiRoU1N COUNTY <br /> 7WOE mr 4-r <br /> ACCEPTED BY: 1 ,MV/fk V J EMPLOYEE#: DATE: <br /> ASSIGNED TO: J r we EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P IE: I �J <br /> Fee Amount: �S Z �� Amount Paid j lj`�� Payment Datev <br /> Payment Type li /� . Invoice# Check# Received By: i) <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />