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SAN JOAQUID )UNTY ENVIRONMENTAL HEALTH _ ,?ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID#I SERVO R C <br /> //i' U I <br /> OWNER i OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS rectioi' GGA✓//�/i'y/� r f03 <br /> ST/OC,Cj,�DI'7 q/ <br /> J! 2`Y / <br /> 3V StreetNumber DiSn sameC/ ()� <br /> Cit Zi Cotle <br /> HOME or MAILING AD,pR�SS (If Different from Site Address) �G�U hyq LAl <br /> /G/9 hA,? ZA// Street Number Street Name <br /> CITY /C� STATE ZIPr2/b <br /> PHONE#I EXT. APN# LAND USE APPLICATION# <br /> (925') 5 Z - 5,S-5_5- <br /> PHONE to EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# Ext. <br /> HOME OrAILING ADD?S�FFS FAX If <br /> 6 GG)d h h ( ) <br /> CITY G (7 STAT Fi1 A ZIP 5Z <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 /> 1 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:�/���A����� DATE: /'3U—ZD <br /> PROPERTY/BUSINESS OWNE49 OPERATOR/MA AGER ❑ OILER AUTHORIZED AGENT El <br /> /f APPLICANT is not the BILLING PART r proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the propertyA ted at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentay/��Ient <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It Is available and at the` <br /> provided to me or my representative. v <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: y,�TIS/RO U/HC <br /> y06 5q/VTM�TtY <br /> ACCEPTED BY: EMPLOYEE#: DATE:a L4 ' <br /> ASSIGNED TO: EMPLOYEE#: 33 Lei DATE: <br /> Date Service Completed (I(already completed): / SERVICE CODE: I I E: r 3 <br /> Fee Amoundd (L Amount Paid /$ �' 6(l Payment Date ZD <br /> Payment Type Invoice# Check# ��[r cT��� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />