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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST pK01�2J4I <br /> Type of Business or Property FACILITY ID# Q SERrVI��CE''RJJEQ IEES�Tr# <br /> VD7� TT <br /> OWNER/OPE ORW 5 C� _ ` <br /> >' CHECK If BILLING ADDRESS� <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direcllon Street Name r1tv Zi Cotle <br /> HOME or MAILIN ADDRF�Ss (If Diffee Tlt from Site�'(Addddrr�e>� <br /> _ y Street Number Street Name <br /> Cl /�/C�,�.f, a, I �� e75-2--67 <br /> �—6- <br /> PONE <br /> STATE ZIP <br /> p� #) 7 z.� Exr. APN# LAND USE APPLICATION# <br /> P��r/q�/ 7/ <br /> G` Y�� BIDS DISTRICT LOCATION CODE <br /> REGI( / 00 CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR� <br /> CHECK if BILLING ADDRESS 010 <br /> BUSINESS N <br /> Pwftol <br /> <—r �^ 71- y' <br /> HOME Or AILING ADDR SS FAX# /Y �J <br /> 711 / g lsel-i <br /> CITY �Tyi/ �i �s„v ST ZIP + n 6 <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 Coder,Standards, STATE and FEDERAJ,laws. <br /> APPLICANT'S SIGNATURE: 1 a� o>[C� DATE: <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHERAUTHORIZED AGENT❑ <br /> If APPLICANT is not the 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 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. <br /> TYPE OF SERVICE REQUESTED: MF <br /> COMMENTS: <br /> e a�iva� ALIS <br /> tS 102 <br /> �^T IN CO <br /> y'.'0 r 1 Y <br /> ACCEPTED BY: EMPLOYEEM DATE: (P Z <br /> ASSIGNEOTO: t�l�V� /mil V t EMPLOYEE DATE: g ltf2/ <br /> Date Service Completed (if already completed): SERVICE CODE: P1 E: <br /> Fee Amount: "UU Amount Pai �S� Df) I Payment Date S G 2 <br /> Payment Type Invoice# Check# �(�8 D Recei d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />