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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �rP co2S X39 X 000-95cici <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> �v J N\3 2 <br /> FACILITY NAME <br /> SITEADDRESSZgao '� 11 _,1` L'J C)C— v\ q,;ZoS <br /> 11 Street Number Direction 1'10.Jt/� treat Name city Zip Code <br /> HOME or MAILING ADDRESS <br /> (if Different from Site Address) <br /> q6 Streat Number Street Name <br /> JiaY .� �� STATE 951Zc7 <br /> PHONE#t FxT. APN# LAND USE APPLICATION# <br /> (,'041-T1t7- j�3y3 <br /> PHONE#2 BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR = ,^ <br /> V W, 1 \ CHECK If BILLING ADDRESS <br /> BUSINESS NAME ` V ?PAIDRiE.,# //� EXT. <br /> Svc uZ:ot(\ / 7 <br /> HOME or MAILING ADORES FAX# <br /> CITY Acc ATEC ci MAMp q -00q <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 appli ' n at the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, S ATE and FEDER L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESSOWNER❑ OPERATOR AGER ❑ OTHE HORIZED AGENT El <br /> IfArPLiCANT is ,at the BILLING PART r 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 and at the same time it is <br /> provided to me or my representative. I� <br /> TYPE OF SERVICE REQUESTED: �0A (�/n(cu <br /> COMMENTS; ell D <br /> Nuoo (, 0� o jut <br /> 20Z, <br /> �ENpllUttyCO <br /> y 17iOZ.H. rA4 7-r <br /> ACCEPTED BY: EMPLOYEE DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SER ICE CODE 11E: <br /> Fee Amount: ��zJ Amount Paid 'GJa Payment Date 2r <br /> Payment Type LIZAInvoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />