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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE)R�QUES T# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> G <br /> SITEADDRESS 'L5$ b2 S SCAnvmC"1 . �� i s 17 <br /> Street Number Direction Street Name Zi ode <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 /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAM h l�W'� C`�S�O�� PHONE# ExT. <br /> ( <br /> HOME or MAILI1 \ FAX# <br /> CITY STATE ZIP <br /> BILLING A( S or business owner, operator or authorized agent of same, <br /> acknowledge 1 ,ALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as Identltlea on nils Corm. <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: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT 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 enviromnental/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:r 17\\p \ _AjZ ye Vv\ <br /> COMMENTS: Se�V;ce, 1e �� T\Y1/�e kcz, \�f\Sp —. 0-Y\ L1k�'KS�C <br /> Tcar•SQ�{�a�o.�`�� <br /> C)Y\ <br /> ACCEPTED BY: EMPLOYEE#: �ooa DATE: <br /> ASSIGNED TO: EMPLOYEE#: O©O DATE: `tO/z 1 3 <br /> Date Service Completed (if already completed): t CZ?) t-22 SERVICE CODE: Q ` P/E.`�,7_l <br /> Fee Amount: 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 �5—/ <br />