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SAN JOAQOCOUNTY ENVIRONMENTAL HEALTSEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR , <br /> CHECK If BILLING ADDRESS <br /> Uomm <br /> FACILITY NAME <br /> SITE ADDRESS , v <br /> l0'J� 1 V C9 � =� L <br /> Street Number Direction Street Nam i iP Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY `�Uctt <br /> $TATE ZIP /1r�Z— <br /> PHONE#1 v ExT. APN# LAND USE APPLICATION# ✓ J <br /> ( ) <br /> PHONE#2 ExT_ BOS DISTRICTLOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 'A <br /> .G CHECK If BILLING ADDRESS <br /> BUSINESS NAME G'C45 5,1C //� "�L} / 7(yj 00 PH �E // ) '1ExT. <br /> HOME Or MAILING ADDRESS /� S7, I /��] �/ FAx•A#I <br /> CITY STATE C 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 a ifction and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standard T E and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNEV' not <br /> OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT the BILLING PAR 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 and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: a IECrr-4VF+n <br /> Nov 0 a 2. 13 <br /> SAIA,OAQDIN COU14 <br /> TV <br /> OT <br /> fovl 0MERTM�T <br /> ACCEPTED BY: EMPLOYEE#: ATE: <br /> ASSIGNED TO: n �t EMPLOYEE#: z DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Z P/E: I Z <br /> Fee Amount: � Amount Paid Payment Date l <br /> Payment Type PATf Invoice# Check# Re eived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />