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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> M66/ � J©) <br /> OWNER I OPERATOR <br /> Mo,r 1 CHECK If BILLING ADDRESS <br /> FACILITY NAME —� J <br /> dA_� `S 1 c uc 0 -Ty-,)c <br /> SITE ADDRESS <br /> Street Number Direction Street Name cityL' Code <br /> HOME <br /> 'o'r\MAILING ADDRESS (if Different from Site Address) Cf <br /> J[j S <br /> Street Number r Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 2-c�'t) F-0 5'0 <br /> PHONE R EXT. BOS DISTRICT LOCATION CODE <br /> (70q) ctg-G - CbSB <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PG�qE"T <br /> U-6 ^ �D y0 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY S �.Lvf�� STATE ZIP C�S ZC S <br /> BILLING ACKNOWLEDGEMENT: 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 /> 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 and EDERAL laws. <br /> APPLICANT'S SIGNATURE: TDATE: <br /> PROPERTY/BUSINESS OWNER IS OPERATOR/MANAGER IJd/ OTHER AUTHORIZED AGENT❑ <br /> If 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 DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: l vvC l (Al cu LAS e-(V F F <br /> COMMENTS: F <br /> qpR <br /> y N��qQ�?8�?0 <br /> �A`TH�Fpq�CO UNry <br /> t <br /> ACCEPTED BY: EMPLOYEE#: DATE: –2� <br /> ASSIGNED TO: NA, EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: CXV l P I E: ) <br /> Fee Amount: I7 Amount PailS7 Payment Date ZU <br /> Payment Type Invoice# Check# Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />