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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 V 111 <br /> SITE ADDRESS �I� � M li t,r�P C A �S -D J' <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site ddress) <br /> 3 ` CxlnA6VE' �Ct Street Number7 Street Name <br /> CITY STATE ZIP G <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> if ala Z <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1 e��� ,// Pe <br /> �U L � I CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> 2�t C <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 form. <br /> I also certify that 1 have prepared this applicat' d that t \ work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,St nd rds,S a F Daws. <br /> /(b <br /> APPLICANT'S SIGNATURE DATE: <br /> PROPERTY/BUSINESS OWNERQOERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: N <br /> COMMENTS: eywii <br /> CDrt t. Czvq) g�3- 76`l 7 �o Sc Prlc� l C� <br /> NOV4W Low <br /> 1 �� <br /> sgNz01g <br /> Oq <br /> ACCEPTED BY: 4ft 14 <br /> EMPLOYEE#: ff4 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: d S/ P I E: 0(Z <br /> Fee Amount: � Amount Paid — Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 1 I n SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />