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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST P R b b 1 23G <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> EtE ► �0- 00lgLf 23� <br /> OWNW OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACumNAM�fie rl� t cy� <br /> SITE ADDRESS err z <br /> 3U Street Number Direction Street Name Cit Zip Code <br /> NOIR r MAILING ADD (If DI rent from Site ddreSS) <br /> .JI �/ Street Number Street Name 2 <br /> Cll�jj V� T ZIP <br /> PHONE#1 EXr. APN# LAND USE APPLICATION# L <br /> Imo) Jf - 17 <br /> 3 <br /> PHONE92 EXT• BOS DISTRICT LOCATION CODE <br /> x - 865 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Crime 131tocw� CHECK If BILLING ADDRESS <br /> BUSINESS NAME J G� e� PON # — SJTEM • <br /> HOME4f MAILING ADO E � �� `Ax# ) <br /> CITY N/ e C STATE ZIP �' �3 5�— <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 a identified on this form. <br /> I also certify that I have prepared this applic n that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA RAL laws. <br /> APPLICANT'S SIGNATURE: DATE: ey <br /> le'pl 41 <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/ AN GER ❑ OTHER AUTHORIZED AGENT El <br /> IfAPPLfCAATis not the BtLLlNGPAR proof of authorization to sign is required Thle <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 environmen site assessment <br /> inf0rmation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at M1i4Ofl ee it is <br /> provided to me or my representative. 1 R e <br /> TYPE OF SERVICE REQUESTED: ,�,t > �� n��LJ aw <br /> COMMENTS: <br /> A4JOQUAP <br /> A(HIC%, l'o?I' <br /> YTS <br /> 'NFNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/ : <br /> Fee Amount: Amount Pa 1552, dP Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />