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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERAOR <br /> 9 ` I` j a ` / j;lOviJ CHECK If BILLING ADDRESS <br /> FACILITY NAME ..�' <br /> SITE ADDRESS l`-I` 1l Uv\. <br /> i <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> I� `� . <br /> Street Number Street Name <br /> CITY STATE �y ZIP <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> PHONE#2i EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR `V ('• , ' <br /> 1\y '� Y. <br /> l' CHECK if BILLING ADDRESS <br /> BUSINESS NAME —17 1 &'3 r l 0 PHONE# <br /> EXT. <br /> HOME or MAILING ADDRESS, J (�M1 J FAX# <br /> CITY -)�J X11 STATE (, ZIP q 5 ZI <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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: t��'I t1 v S,�,lu DATE: oL—li` <br /> 5— <br /> PROPERTY/ <br /> —PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 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 a�at the same time it is <br /> provided to me or my representative. M <br /> TYPE OF SERVICE REQUESTED: �,��i^I v+�Su, `t�1ti _ CE/>V <br /> COMMENTS: i11 A Q V lL�\ G�` V V��JIk-UL`��V y` MA Y 15 202 <br /> S,an,ryI0 <br /> l ERCINiN COUNl.y <br /> HEALTH pE�RTMENT <br /> ACCEPTED BY: >�,V'1 EMPLOYEE#: DATE: 5— <br /> ASSIGNED TO: L EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE: <br /> Fee Amount: AL. .� _ Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />