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p SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# . SERVICE REQUEST# <br /> colko n -" ( �A o00 3�30 -S�'(D 0 Z <br /> OWNER I OPERAT <br /> CHECK if BILLING ADDRESS 13 <br /> J 0 W n &Oasmur) <br /> FACILITY NAME <br /> SITE ADDRESSI 1 1. / I I ��,. �re4 C"t L53�-1�! <br /> Street Number Direction Street Name C_I 1 Zip Code <br /> HOME or MAILING ADDRESS If Different f,r�rro--�m�II Site Address) <br /> SSStit Sheet Number "at Name <br /> CITU <br /> MMAOTATE <br /> PHONE#t �r )!n EXT. APN# LAND USE APPLICATION# <br /> (7,M) q 319 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAMEl— PHONE# EXT. <br /> __Tci G o <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE 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,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S •SIGNATURE: E DATE: <br /> PROPERTY/BUSINESS OWNERL4 OPERATOR/MANAGER AUTHORIZED AGENT <br /> If ADPL/CANT 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 t0 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: t Y <br /> COMMENTS: <br /> SAN✓O `8 ?020 <br /> FNS qQU/ <br /> h�9lTH0 pMFNTJ <br /> ACCEPTED BY: EMPLOYEE#: �f > DATE: <br /> ASSIGNED TO: 1 EMPLOYEE#: SI Jam[' DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: u 1_ P 1 E� (v(p Q <br /> Fee Amount: Amount Paid (�a Payment Date 120 20 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 1p SR FORM(Golden Rod) <br /> REVISED 11/17/2003 pr_01'(014F 0 <br />