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0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ( �Ii e SDI on a tJ 5 JO00SZ-:713 <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS1 � f COt OWL'D <br /> Street Number Divd- greet Namecity 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 /> (XI ) M3- 1019 OZ <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR ����^ <br /> 1 J CHECK if BILLING ADDRESS <br /> BUSINESS NAME �I ,,` �o PHONE# ExT. <br /> 1�Jz S 7 on QZ t a38 a <br /> HOME or MAILING ADDRES FAX# <br /> �i ?i -�S�to <br /> CITY STATE ZIP <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 FEDERAL laws. __^^ <br /> APPLICANT'S SIGNATURE: DATE: c)o o y <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPzacaur is not the BILLlNGPARZY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When apperator of the property located at the <br /> above site address, hereby authorize the release of any and all rVand/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENvutoNMENTAL HEAL as it is available and at the swne time it is <br /> provided to me or my representative. �/��N 1 <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> GOVt.1N <br /> SAN JO RoNMENTA�N.f <br /> VA LW"pEPpRTM <br /> ACCEPTED BY: EMPLOYEE#: DaLD <br /> DATE: <br /> ASSIGNED TO, EMPLOYEE#: o ()O DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: 9% Amount Paid J oZe71 f, �-� Payment Date <br /> Payment Type Invoice# Check# j (�55� Received By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />