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SAN JOAQU- -OUNTY ENVIRONMENTAL HEALTH PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S <br /> OWNER/OPERATOR <br /> 1,71— C- CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS ' a <br /> � T t- EjV <br /> Strumber : c,,ireon Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ($t8► �{�-t l —ci-ci 1 3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME \ 1-411 ��T{Z� PHONE# <br /> EXT. <br /> l �ociL.�- ��VC l 3Ci <br /> HOME or MAILING ADDRESS FAX# <br /> S <br /> CITY C� STATE ZIP �+ Q Z k <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 the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE an laws. <br /> APPLICANT'S SIGNATURE: DA l E 1 o p(„ <br /> PROPERTY/BUSINESS OWNER❑ OPERAT ,ER ❑ OTHER ALITnORIZF:D AGF:N'I' E.`+► <br /> /f APPLICANT 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 DEPARTME [T ass on as it is available and at the same time it is <br /> provided to me or my representative. , J ^� <br /> TYPE OF SERVICE REQUESTED: (,( S T Imo' c�yC I T a �j <br /> COMMENTS: <br /> SPN 30 P <br /> NEP A <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: D DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: cl (S'- P I E: O <br /> Fee Amount: .-�S, t,� Amount Paid is Y)(� Payment Date <br /> Payment Type Invoice# Check`# S 2 O d Received By: N <br /> EHD 48-02-025 ORM(Golden Rod) <br /> REVISED 11/17/2003 <br />