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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FA 4,;�H e5200s23-Z0 <br /> OWNER/OPERATOR <br /> CA <br /> ` CHECK If BILLING ADDRESS <br /> A .FACILITY NAME —AME AM \— r <br /> SITE ADDRESS ' S-4 l --k\—FH T�—> DP <br /> Street Number Directio lee e city <br /> _" I CJotle YJ <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1ExT. APN# LAND USE APPLICATION# <br /> Q0q) D3a � <br /> PHONE#2 EXT, BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> DELI /� ^ f I CHECK If BILLING ADDRESS <br /> MS <br /> BUSINESS NAME �Y I V P NE# ExT' <br /> \LID - A\P 9- <br /> HOME Or MAILING ADDRESS FAx# <br /> S M R- D I I ) <br /> CITY NN--F e-cla STATECA 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 <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,Standards, STATE d FEDE ws. <br /> APPLICANT'S SIGNATURE DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> /f APPL/CAT is not the BILLING 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 <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: V t�1t/\'L O V✓`��/LQi✓L D l/lK� A..J G 1 — /l'J "'��" AY/1" <br /> SAM �O <br /> ACCEPTED BY: TAve-'S/' W EMPLOYEE <br /> ASSIGNED TO: �rA EMPLOYEE#: DATE: FP,q,R6/%r- <br /> Date Service Co plete1d'(,if ahead)completed): SERVICE CODE: I PIE: I Lp <br /> Fee Amount: v L Amount Paid A �/� Payment Date �- 0 D <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />