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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/OPERA,(OR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS z 3o N(�,�/�/ ��/� �d Z 7 <br /> i <br /> et Number DIrecllon / 1s reef Nam t Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT APN# LAND USE APPLICATION It <br /> QOq ) 5 5/j <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> 409"R, <br /> BUSINESS NAME — m� j� � <br /> PHONE# � S �/ Exr. <br /> HOME or MAILING DRESSd ` FAx# <br /> J/ / <br /> CITY / STATE ZIP ��Z <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 a)d that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE n •EDERAL S. `z <br /> APPLICANT'S SIGNATURE: DATE: Z <br /> PROPERTY/BUSINCSSO\1'NCR❑ PE&1 OR/RLINACE OTI RAU'TIIORILEDACE ! !9C <br /> IfAPPUGtArT is to )e B/1,1.! G P,IRTS' I)!'00,Of(/l!l/lOrl (dlol!i'0 sign%S YL'(Ipp'L'l/ Tile <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/sitc 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: `.) _�' �7 ^v cl,U C, 1 <br /> -luc. z 9SAN zoz� <br /> N SNV/RO)V COUNTI' <br /> ACTH p�pARTTAf <br /> ACCEPTED BY: � EMPLOYEE#: DATE: -> <br /> ASSIGNED TO: EMPLOYEE#: -2> "� DATE: ' -Z(I. 7f)Z� <br /> Date Service Completed (if already completed): SERVICE CODE: �) J/ P I E: ?C <br /> Fee Amount: ( Amount Paid a �� Payment Date =f-2q 2 o <br /> Payment Type Invoice# I Received By: <br /> EHD 48-02-025 SR FORM(GOI( <br /> REVISED 11/17/2003 <br />