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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ��SERVICE RE(;WEST# <br /> OWNER/OPERATORECK If BILLING ADDRESS <br /> I0�3 <br /> C aQ los L- L U{ �• CHECK <br /> FACILITY NAME l <br /> I ali°+a/Lo 5 Do. //CO�I�s <br /> $READDRESS 3!3 bo- // fy^ Sr- ! 1^ZS.�� '5326 <br /> Street Number DirectionStreet Name Zip Code <br /> HOME or MAILING ADDRES/,S/(If DlffereT from ite Address) <br /> �s �'✓' S S Street Number Street Name <br /> CITY —7— STATE ZIP�S / <br /> ! rIL r, ,46 <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> Odd )QIN'91 --q <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1 <br /> C0��t2s � CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHQNE# EZT. <br /> Tau%[es <br /> HOME Or MAILING ADDRESS 2/ s! S FAX# <br /> J 77 5 /f4 �S3 r� ( 1 <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:�.11 E: DATR: / < S- II <br /> PROPERTY/BUSINESS OWNERO OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> If APPLICANT 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. p <br /> TYPE OF SERVICE REQUESTED: Rd F <br /> COMMENTS: Seto 0 F <br /> %'/0. � ?pl9 <br /> HGF/i � -4 ll <br /> ACCEPTED BY: WtA EMPLOYEE DATE: t--T / <br /> ASSIGNEDTO: Kmwoc �• EMPLOYEEM qr3– DATE: r✓ <br /> Date Service Completed (if already completed): SERVICE CODE: GJ-�. P1 <br /> Fee Amount CP -FAT I Amount P `7�� O� Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />