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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME U' v (\Y1Gl• �.��tC0.� ` t <br /> SITE ADDRESS1^ O CJ Y V`C �� C.� C�C c kck c� <br /> Street Number Dlrectlon L t Name J VcityZI Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITU fA _ TATE qZ -2-0 <br /> PHONE#1 V l EXT. APN# LAND USE APPLICATION# <br /> 12 `l 600 U 4� 6 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME T l �1ex` I PHONE# 6 GZG EXT. <br /> KA.0 t S <br /> HOME or MAILING ADDRESS FAX If <br /> CIN G� STATE r <br /> ZIP C <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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: :G lS Q (� O " z-a��' Z DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> I,fAPPLICANTisnot the BILLING PARTY proofofaulhorization 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 andysame time it is <br /> provided to me or my representative. n '�7M1' <br /> TYPE OF SERVICE <br /> REQUESTED: WI����/�� �/JU�Y1t.,�,V��,,n <br /> COMMENTS: <br /> H��Q'O)V�0��TY <br /> ACCEPTED BY: y,rAA tnt s.�� EMPLOYEE DATE: 1-0-20 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: JU61 <br /> Fee Amount: v1 2 -D) Amount Paid a b� Payment Date <br /> Payment Type Invoice# Check# 11 3 (J (Q Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />