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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS <br />_ FACILITY ID # <br />«� <br />CJ\ <br />SERVICE REQUEST If <br />T; <br />OWNER/OPERATOR / <br />,v\ <br />Atbe IZ� 'W n� <br />CHECK If BILLING ADDRESS <br />FACILITY NAME Ch <br />IS <br />DATE: <br />SITE ADDRESS Zt�l-I� <br />' Street Number <br />S <br />Direction <br />,I�O�QI-w c>'Z f— OZA...,t <br />T� ' r' Street Name _ <br />Y <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) I tQ <br />13 <br />Steer�e Number <br />, <br />I 1 <br />A _ �v <br />-�n�r-� Street Name �— <br />CITY } <br />STATE OA <br />n ZIP '15-2-1 <br />P_1iONE ; U \l� Ea'• <br />I lc- ( l� <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 ErT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REOUESTORL <br />Vy� <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME GI/1 /1.�� lC <br />, <br />«� <br />CJ\ <br />PH E0 1 ( EXT <br />## (� <br />HOME or MAILING ADDRESS <br />I <br />FAX <br />CITY )� GI / J� v, <br />STATE ZIP <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 FERE L laws. <br />APPLICANT'S SIGNATURE: \1 % DATE: <br />N v � <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/MANAGER❑ OTHER AUTHORIZED AGENT <br />IfAPPL1CANT is not the BILL/NG 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. w <br />TYPE OF SERVICE REQUESTED:G <br />COMMENTS: <br />OFC t <br />0 9 0 <br />-"9[�/j�FpMIFtCpT��iY <br />ACCEPTED BY: <br />Ivv <br />EMPLOYEE#: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Co <br />pleted (if already completed): <br />SERVICE CODE: <br />P1 E: <br />Fee Amount: <br />•0 <br />Amount Paid <br />i� <br />Payment Date <br />' G) <br />Payment TypeNa <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />?Romvs 1- <br />I& <br />SR FORM (Golden Rod) <br />S <br />