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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> P-e5j". � ODI ?-u 0�P S'�2 0(D2 549q <br /> OWNER/O �OERATOR/'' CHECK If BILLING ADDRESS❑ <br /> T(ILrt9 ua MrA <br /> FACILITY NAME '^ <br /> SITE ADDRESS ,. Y \�( �„/ I�f Ll U' <br /> Street Number Direction l..kN t VJ / 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 Ezr. APN# LAND USE APPLICATION# <br /> PHONE Ex. BOS DISTRICT LOCATION CODE_, <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> ,I <br /> BUSINESS NAME ��r. x-11 �r PHONE# ER'( ) <br /> HOME or MAILING ADDRESS <br /> FA%# <br /> _�LIQ K <br /> CITY L V' / STATE C ZIP gC"1Q Cy <br /> BIIIJNG 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,ST T/&aEDIERAL <br /> laws.APPLICANT'S SIGNATURE:? //11 DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY 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. P <br /> TYPE OF SERVICE REQUESTED: Cit 04b T <br /> COMMENTS: e K<y,A &l }oc <br /> (J l•l <br /> VNw�oU/N COU <br /> HST H DF M NT <br /> ACCEPTED BY: EMPLOYEE#: 7) DATE: 10111 / 7 <br /> i <br /> ASSIGNED TO: EMPLOYEE#: DATE. t�* I/ ZZ <br /> Date Service Com eted (if alre dy completed): SERVICE CODE: P/E r— 1: 1 coy <br /> Fee Amount: Amount Pai 1s7, ,0 D Payment Date /b 11 �_ <br /> Payment Type Invoice# Check# R ceiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />