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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> fil <br /> OWNER/OPERATOR <br /> V <br /> _0 e-C &Vct r CHECK If BILLING ADDRESS <br /> C <br /> FACILITY NAME �/ D <br /> ( - V <br /> SITE ADDRESS ((11� lam/ 5s r, (�U \��^ Z C�b <br /> ��Street Number Direction J\\� tree[Name Cit i Code <br /> HOME"AILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY C r STATE[ ZIP <br /> J V Vv �Zdb <br /> P NC#1O� Exr. APN# LAND USE APPLICATION# <br /> PHONE#Z EXT 80S DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME G� P ONE �9''�nCrJs �,. V�►v�c, _l <br /> HOME or MAILING ADDRESS a FAX# <br /> CITY STATE j ZIP T5-e'4, <br /> 1 <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 /> 1 also certify that 1 have prepared this applicatio and tha a work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE a d s. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> 1fAPPLICANT 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 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 Ine or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> A4 <br /> h+ r/'; /IV CO <br /> Ty D�pq FNT�t <br /> ACCEPTED BY: I O�A t/ EMPLOYEE#: ( ��j DATE: <br /> ASSIGNED TO: l• /J ( EMPLOYEE#: a DATE: <br /> Gl <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: ! <br /> Fee Amount: G'� Amount Paid /1e�� lPayment Date <br /> Payment Type Invoice# Check# Received By: ' <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />