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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> � 2 �"-)p54S ---S3 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME 6 d O <br /> SITE ADDRESS �� I� IC iJv�2 C411 <br /> Street Number Direction ( Street Name Cit 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 /> ( ► 17 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTO t✓r•',A <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> g 3Sb — I Z-94'k <br /> HOME or MAILING ADDRESS /, / rQ C FAX# 2 <br /> aem <br /> CITY 1 n ; STA ZIP <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 ENVIRONMENTAi.HEALTH DihAR-rMI:N'r 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 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 FF.DFIXAL laws. <br /> APPLICANT'S SIGNATURE: DATE:_ <br /> PROPER11'/BUSINESS OWNER❑ OPERA'FOR/MAW.ERE] O'HIERAUTt10RIZEDAGENTE] a -e" <br /> ff APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title 14 <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 DI:PARTMENr as soon as it is available and at the Same time it is <br /> provided to me or my representative. �N <br /> TYPE OF SERVICE REQUESTED: j,C-S T "'7y2-Ej RecEN <br /> COMMENTS: `u i -.i- <br /> SAN <br /> SA EN� QUIN R NMENTALTM <br /> IjEALTH DEPARTMENT <br /> ACCEPTED BY: C (L) EMPLOYEE#: DATE: (C cy i <br /> ASSIGNED TO: l/ &+( I�W(� EMPLOYEE#: 1;L 61-7 DATE: a- <br /> Date Service Completed (if already completed): SERVICE CODE: { P/E: Z 3 r-S' <br /> Fee Amount: U l i Amount Paid � 1A . Payment Date \� Q <br /> Payment Type ✓ Invoice# Check# -2— Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />