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SAN JOAQUSOUNTY ENVIRONMENTAL HEALTI&PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property Co U't'�J 0 'kz Q FACILITY ID# SERVICE REQUEST# <br /> r✓6L Pi.s eA--5<A:'G rA,Cr Lr f �-�,q 0 3 7 ef 7 � d y�)5 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> I �/� <br /> FACILITY NAME :�,FFS Z)11 A /) *eALX f — 7 <br /> SITE ADDRESS ilk �.{f•vtp r <br /> 0Z)b Street Number Direction Street Name Ci Zi Co e <br /> HOME or MAILING ADDRESS (If Different from Site Address)e. <br /> I ele <br /> Street Number Street Name 6-v x <br /> CITY J%�L o-- '0 STATE c.4 ZIP 17ctl '(^t y o <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (>zv ;qEg —3 1 t 6 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQU <br /> ESTOR <br /> REQUESTOR -'C;C`�� j� L"n �/ 61J CHECK If BILLING ADDRE <br /> BUSINESS NAME (�J / �Cv ,j PHONE# ExT' <br /> pi �Ir 6�c s-R f x—1 S&S /At ' C 6 <br /> HOME or MAILING ADDRESS FAx# <br /> -2,376 M ) 3 1r <br /> CITY n/ STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized rsagent 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,S TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 4 <br /> IfAPPL/CANT i Ot 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 sment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the s <br /> provided to me or my representative. �� r <br /> TYPE OF SERVICE REQUESTED: �a/61 / (_ e'4-_f <br /> COMMENTS: <br /> 17* <br /> ACCEPTED B EMPLOYEE#: DATE: 1 <br /> ASSIGNED TO: EMPLOYEE#: 2` DATE: (/ <br /> Date Service Comp eted (if al ady completed): SERVICE CODE: t P I E: 20 b <br /> Fee Amount: Amount Paid Payment Date 4, <br /> Payment Type V <br /> Invoice# Check# ael Z <br /> Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />