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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SSnE,�R,,V��,IICE REQUEST# . <br /> 02f OS J�I20V (p/4 &0 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS E] <br /> FACILITY NAME <br /> p/' D lie <br /> slT3So 6 <br /> Street Number I Direction I ual �Slr� ame Ci ZI Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EM APN# LAND USE APPLICATION# ' <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT, <br /> q o r 3 a <br /> HOME or MAIADD 5 FAX# <br /> LA <br /> CIN b STATE ZIP <br /> BILLING ACKNO'LEDGEMENT: 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 or <br /> 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 F ,RAL laws. /r r <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS 02? OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the B1LL(NGPARTY proOfof altt/eoriZatiou 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. POOL1, -u'� Q„>c.P�}[ 1-4-.-c o�L y'r_�4-N 1�FF£c(C <br /> TYPE OF SERVICE REQUESTED: /3 l- 4-dM <br /> COMMENTS: DO <br /> f' MEN I <br /> RECEIVED <br /> SIA/f�yey' <br /> NOV JO 1 12010 <br /> '1 ✓, ID <br /> SAN JOAQUIN <br /> / <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: 6at'3 DATE: <br /> ASSIGNED TO: Y EMPLOYEE#: &"Z/3 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �a� PIE: 360 <br /> Fee Amount: gout(- Cab Amount Paid 4 y _ Payment Date ,\ 16110 <br /> Payment Type f Invoice# Check# SS 6 O Received By: N/Z, <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />