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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> sv,?, 3102 <br /> OW R/OPERATOR <br /> S & CHECK if BILLING ADDRESS <br /> FACILITY NAME ( UDI <br /> SITE ADDRESS � `JP1" <br /> 17 <br /> Street Number Olm on Street Name I 21 Cod <br /> t OrILING ADDRESS (If Different from Site Address) ^ <br /> Sheet Number � `� �'S reef Name <br /> CITY/ n�� STAT zip 9'(-2— <br /> t' 4-/ <br /> `/ <br /> ( 2 /.^1 <br /> PHO(E/#-/ Ems• APN# LAND USE APPLICATION# <br /> ( 2,13 D 2 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR A—W ,/I,I/1\ 9 ^//Y/X1 4J ogo;�OZ CHECK if BILLING ADDRESS <br /> BUSINESSNAME `,� 1 ,c I - /�/I/� PHONE# ExT <br /> HOME or MAILING ADDRESS c � FAX# ) <br /> CITY / _1 STATE zip Gl' rj <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 roe or my business as identified on this form. <br /> I also certify that I have prepared this 3pplication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standang,ST TE and FEDE L WS. ' I � G <br /> APPLICANT'S SIGNATURE: �- <br /> DATE: I -, 12.A <br /> OPERTY/BUSINESS OWNER ' OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICA isnotthe BILLING PARTY 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 environmentallsite 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: oht C'V- RECEftfo) <br /> COMMENTS: <br /> APR 2 8 202 <br /> SAN JOAQUIN COW TY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTM T <br /> ACCEPTED BY: EMPLOYEE#: J�) DATE: <br /> ASSIGNED TO: l / EMPLOYEE#: v DATE: 'L/ <br /> Date Service Completed (if already compile-ted): SERVICE CODE: 3 ,,:1 <br /> Fee Amount: '00 Amount Paid _ Payment Date ff 7-1' 2,!9 2, <br /> �I <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 c SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />