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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S2 acs <br /> OWNER/OPERATOR .\ <br /> U CHECK If BILLING ADDRESS <br /> E <br /> FACILITY NAME \ <br /> SITEADDRESS <br /> "�9"A`�'}� \l� 1'I� <br /> tIV\Number Direction V ` eOt Wme -l�" 'Cit <br /> HOME f JIGA G ADWSS I�Dltfer nt from Site Address) <br /> �`�� '<C•�.`le) W W Street Number Street Name <br /> CITY STATE F\ ZIP C <br /> P NE#1 ExT• APN# LAND USE APPLICATION# (� <br /> ) 22�'\- <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME r PHONE# �� N EXT <br /> 1 _ (J\ <br /> HOME or MAILING ADDRESS \^ ^ FAX# <br /> V ( ) <br /> CITY \ STATEC 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 /> COLINTY Ordinance Codes,Standards, Sip E FEDERAL laws. n r� <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER)�'j`'� OPERATOR/ ANAGER ❑ OTHER AUTHORIZED AGENT El <br /> If APPLICANT is not the BILLING PAR TP 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 the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or enviromnental/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: M n <br /> COMMENTS: <br /> RECE VED <br /> APR ?8 ?p21 <br /> I y JOAO <br /> Rwo-YIN C <br /> LA <br /> ACCEPTED BY: O I �I CO S EMPLOYEE#: g`�0 <br /> ASSIGN ED TO: EMPLOYEE#: Q J DATE: V/2 <br /> Date Service Completed (if already completed): SERVICE CODE: I P/ <br /> /E: <br /> Fee Amount: I J VV I Amount Paid Payment Date <br /> :ZJ.'4— <br /> Payment Type Invoice# 2L{' X202 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1111712003 <br />