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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/OP EI iATOR CHECK If BILLING AoDRFSZ] <br /> r il 0,�c? cii 01/' C?h- <br /> FAciLrryNAME <br /> SITE ADDRESS <br /> —5&q Street N11Mber I Name T W <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE$1 Exr. APN# r= rLAND USE APPLICATION# <br /> (pfd ) (Pqg -,5-7/,3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> c" <br /> CONTRACTOR SERVICE REWESTOR <br /> REQUESTOR CHECK It BILLING ADDRESSO <br /> BUSINESS NAME PHONE I ExT. <br /> HOME or MAILING ADDRESS FAx# <br /> CITY STATE 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 ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated With this project or <br /> 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 th*the work to be performed will be done In accordance With all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEMERAL""wSt, <br /> APPLICANT'S SIGNATURE: DATE: 70 <br /> PROPERTY/BUSINESS OWNER 19 OPERATOR/MANAG" OTHER AUTHORIZED AGENT M <br /> If APPLICANT IS not the BILQAir,PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environ m enta Vsite assessment information <br /> to the SAN JOAQUIN COUNTY ENvIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time it Is provided to me or <br /> my representative. PA V a <br /> TYPE OF SERVICE REQUESTED: 1PSPCC-t1"0YJ r <br /> COMMENTS: <br /> AUG D <br /> #V <br /> P, <br /> I�%N, <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> �S7-7 75 cil( 4it <br /> ASSIGNED TO: EMPLOYEE M J r <br /> >4:x=� DATE: <br /> Date Service Completed (if lready completed): SERVICE CODE: 1 PIE. <br /> -7 <br /> Fee Amount: Amount PaIP / W Payment Date <br /> Payment Type Invoice# Check# Received <br /> EHD 48-02-025 SIR FORM(Golden Rod) <br /> 07/17108 <br />