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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE E? ST#, <br /> �C <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> U L CN c <br /> FACILITY NAME <br /> CL' /A►2Tz R SGHr70L <br /> SITE ADDRESS 99 S ,�0�7]`2 lZd tD 7RACy /,� <br /> 3 <br /> o <br /> Street Number Dlrectlon Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3 14Op fo cc 77� �oSTF a2 <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> IZ c (A 15-3104 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> may' ► �t55_31� -`�� r of <br /> PHONE#2 EXT. BOSDISTRICT �- LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS❑ <br /> 17o til C�F�5�f E � <br /> BUSINESS NAME / PHONE# EXT. <br /> loN S a L- < <br /> HOME or MAILING ADDRESS FAX# <br /> Qo -7,r ( ) <br /> CITY fOL STATE ZIP S <br /> Ll <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 aonlication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards ATE and AL laws. <br /> APPLICANT'S SIGNATURE: DATE: g/�3 ,52 0 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLICANT 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: L &j C' -4 ,--EK ,er P c n/ <br /> COMMENTS: 0"-Ts <br /> , _ 1 i S �O <br /> Vv SqN A�� 14 20?0 <br /> E/y I AQU/N C <br /> NEALTH ON qR��NTy <br /> ACCEPTED BY: 1 EMPLOYEE#: DATE: <br /> ASSIGNED TO: a C' EMPLOYEE#: DATE: i?//3JaCU <br /> Date Service Completed (if already completed): 44 SERVICE CODE: PIE: yd()f <br /> Fee Amount: 4 3ZD-I Amount Pai 30�.-'�)'D Payment Date <br /> Payment Type Invoice# Check# 3 / Received By: / <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />