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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUpESTT# <br /> t� 00T; oa l7 <br /> OWNER/OPERATOR /{ y <br /> CHECK If BILLING ADDRESIn <br /> FACILITY NAME <br /> SITE ADDRESS ' <br /> Z?rStreet Number Direction Street Name Cit Zl Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> ,17,131 G--, Street Number Street Name <br /> CITY c� Ur`lL STATE nip <br /> PHONE#t EXT APN# LAND USE APPLICATION# <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME / PHONE EXT. <br /> ( c ) >), 7-5) �9h <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY SATE IP <br /> u c. r a <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. <br /> APPLICANT'S SIGNATURE: ;1 DATE: /J z PAPAYMENTPROPERTY/BUSINESS OWNER - OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ RECEIVED <br /> ED <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title I <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property locattq I L2021 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/ dOAFIM"OUNTY <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sa5✓tfti'"bNTAL <br /> provided to me or my representative. t, HEALTH DEPARTMENT <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: S <br /> `-F C1C <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ` P/E: Lt Z <br /> Fee Amount: / -- Z Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />