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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACIL/IIT��Y ID# SERVICE REQUEST# <br /> V e7!�J <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS ar <br /> FACILITY NAME <br /> SITE ADDRESS, • -d <br /> Street Number Direction tree/Name city Zip Code <br /> HOME or MAI ING A1DD SS (If Different from Site Address) p �k e C -6111/.� 6)� <br /> �i \ � ` Street Number L Street NCam(e� " <br /> CITY ,4- C iJ STATE ZIP <br /> t% Q <br /> PHONE#1 ��/ EXT* APN# LAND USE APPLICATION# <br /> qo� V6 <br /> PHONE#2 n O EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOki)tdtlm R <br /> ��/� <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME Fd1l PH ( EXT. <br /> PHONE <br /> H �MAy � RES� FAx#a <br /> L ( ) <br /> CITY C - �V�1 N t STATE Z-/- <br /> A 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,StandaZmz!�� DATE: <br /> ws. <br /> APPLICANT'S SIGNATURE: _ f <br /> 6 �/ &a <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 and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 01 r <br /> RECEIVE® <br /> ou)(Ier>h P JuAI 0 4 1020 <br /> SAN JOAQUIN <br /> EINO Co <br /> ACCEPTED BY: LOL LA l CC EMPLOYEE#: DATE: p <br /> ASSIGNED TO: V EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: P16: <br /> Fee Amount: n Amount Paid J D� Payment Date o-o <br /> Payment Type LWAlkInvoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />