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I <br /> I _ <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> DrZgq�5i? s <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> - ' V G &VqAJt ®Ll W 5711 )1vl�' <br /> FACILITY NAME 1�L <br /> SITE ADDRESS <br /> -"IV <br /> g <br /> Street Number n�Di/rec'tlon I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) 2-40/rl ��® ©� <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> l ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> 94 y <br /> BUSINESS NAME PHONE# ExT. <br /> LSO r �1�1�L <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE A ZIP Cv <br /> BILLING ACKNOWLEDGEMENT: 1, 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, TE and FEDERAL laws <br /> APPLICANT'S SIGNATURE: DATE: /� /�y! <br /> PROPERTY/BUSINESS OWNER❑ OPE R/MANAGER❑ OT, <br /> AUTHORIZED AGENT CISf��2J/C' - r"° <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title "IeLJC//4'YL <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the <br /> I above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite assessment <br /> f <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. IPFO <br /> �N[ <br /> TYPE OF SERVICE REQUESTED: S t fQ,pQ t J rQ`(-1 PV *4 <br /> �1 {{ <br /> COMMENTS: 20\\ <br /> cOQFt � s� �y,ENTTM <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 60 P 1 E: <br /> Fee Amount: x'00 Amount Paid � Payment Date _ 17/7/t/ <br /> Pa ment T e Invoice# Check# iD Received By: <br /> Y yp I <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> Y <br />