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P I W.L. �) � b 09 2 e) <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY 1D# SERVICE REQUEST# <br /> 0 �.,� #� -�S GAON y q 0s <br /> OWNER I OPERATOR <br /> . 1 OA d,S' CHECK If HEELING ADDRESS <br /> FACItmNa�tE Vc�1�1 0— &,;a '� +► k YIL <br /> SITE ADDRESS e--VAS�O <br /> i- rstreet Number Direction - t r SDtl7a[]me +� crtyP Code <br /> HOME Or MAILING ADDRESS (1f Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE LP <br /> PHONE#1 ExT' APN# LAND USE APPLICATION# <br /> (SN J) 'Dk 1.Z y 2 ko <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONF# ExT• <br /> HOME Or MAILING ADDRESS FAX# <br /> ( ) <br /> CrrY 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. 1 <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNE ERATOR A 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 anZZY& <br /> santr time it is <br /> provided to me or my representative. <br /> TYPE OF SERVECE REQUESTED: V:3, w--- ca W tU 2a C <br /> COMMENTS: <br /> SAN Jpq� <br /> 4 MENfl�NrY <br /> RWvr <br /> ACCEPTED BY: `, \ �, EMPLOYEE#: DATE: <br /> ASSIGNED TO: ^r C, , EMPLOYEE#: DATE. 1 <br /> Date Service Completed (if already completed): ��ISERVICZCODE: PIE: <br /> Fee Amount: 1 Amount Paldlsa ()D Payment Date l _ 2 <br /> Payment Type Invoice# Check# S Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> RE=VISED 91/17/2003 <br />