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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 It BILLING ADDRESS <br /> F ct,co-S <br /> SITEADDRESS /��� .� <br /> Street Number � D rectlon Street N.mo cityCotle <br /> HOME Or MAILING ADDRESS (If Differenttfjom Site <br /> t{eAddress) <br /> -fec cloJZ-/v Street Number Street Name <br /> SfoC t/kl STATE ZIP 20 <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> (2o9$ S 1 b1O 15 <br /> PHONIER EXT' BOB DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> te REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ex . <br /> HOME or MAILING ADDRESS FAX# <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 farm. <br /> 1 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�D S;inOA !7 CYYe YG DATE: Y 7- - O20 <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER <br /> ,,❑ OTHER AUTHORIZED AGENT 11 <br /> If APPL/cANr is not the BILLING PARTY proof of authorization to sign is required rit t e <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: Tivti vpmI 1V) GIVI AAA[� L <br /> COMMENTS: <br /> RS Ewr <br /> FAD <br /> sqN UL 161010 <br /> E AQUI <br /> ACCEPTED BY: EMPLOYEE#: OF <br /> ASSIGNED TO: EMPLOYEE#: 12 :32, 1 <br /> DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: �Z� PIE: b�oYJi <br /> Fee Amount: 1� J Amount Paid Payment Date 2� <br /> Payment Type- Invoice# Check# Received y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />