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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �FLJe i A - C- :A <br /> OWNER/OPERATOR <br /> J ��/ ' . �Y\ CHECK HBIWNG AGGRESS <br /> FACILITY NAME . 1 L <br /> SITEADDRESS c �,q,y� �T -R poy\ <br /> 3 3 Lp Street Number I In aVeet N me city Zip Code <br /> HOME or MAILING ADORESS (If Different from Site Address) <br /> 5 p\ C) n. 1 S".t Number <br /> CITY STATE CA LP <br /> PHONE#/ E)rT• APNaLAND USE APPLICATION# <br /> cacq) 6 3,2 -6no LP I I G1 <br /> PHONE#2 Ezr. BOS DISTRICT LOOAnOJrL6oIfE <br /> ( Ll) Stn - I.n a y <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK N BILLING ADDRESS <br /> BUS E 1 PHONE# — ' <br /> t \ t <br /> OME Or MAILING ADDRESS L,2 FA%# <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: DATE: In <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> /fAPPLIc 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 die <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 JoAQu1N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it i3 available and at the same time it is <br /> provided to me or my representative. w <br /> TYPE OF SERVICE REQUESTED: {�/ A <br /> elz <br /> COMMENTS: (v{(A jaa Cil -7 Cc)-Lvex CLQ.e•I•u 19C111- <br /> n Cll l-A <br /> // ff ( j 0N <br /> y � eco��,J <br /> ACCEPTED BY: p`✓T C r, EMPLOYEE#. ` 1 DATE: d <br /> ASSIGNED TO: Itik c.—,t5 EMPLOYEE#: —\S� DATE: �� .7 <br /> Date Service Completed (if already completed): SERVICE COGS: Y2-3 PIE: 66 ( <br /> Fee Amount: Amount Paid Payment Date J p & / <br /> Payment Type i Invoice# L CIh/eck#//�,�J�� 141-7— Received By: <br /> EHD 48-02-025 PA b`( C`'r t e arA V I a e "' I�a (� 3� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />