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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST PIeL7SG` r- I$ <br /> SERVICE REQUEST# <br /> Type of Business or Property FACILITY ID# <br /> SkClln )GJ Ice, tYCA)1 e✓ <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> U5 ca Ian <br /> SITE ADDRESS <br /> Street <br /> Nu Number Direction S[reet Name d�[ CIt LCl \ZIJ'C�oda <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> t I Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 Eu. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> L \J <br /> ) ! v (ACHECK If BILLING ADDRESS <br /> BUSINESSNAME 7 PHONE# ExT. <br /> rnS <br /> ( 9tis ) <br /> HOME o^rr��MAILING ADDRE$ FAX# <br /> 11 CA ( ) <br /> CITY ! 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 /> 1 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 FEDERAL laws. 1 <br /> APPLICANT'S SIGNATURF4— l Ul C7 }Y I Ch� DATE: <br /> PROPERTY/BUSINESS OWNER 0 OPERATOR/MANAGER ❑ OTHER ADTHORIZED 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. rr <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: SM O <br /> �® <br /> zozz <br /> ENV,UINCOU <br /> Fi1LTh0 pA MANn <br /> ACCEPTED BY: EMPLOYEE#: % 2,( DATE: <br /> ASSIGNEDTO: EMPLOYEE#: L D 44 DATE: ( t .L2 <br /> Date Service Completed (if already completed): SERVICE CODE: Wo I PIE: 4„(,I o3 <br /> Fee Amount: Amount Pa'VePayment Date 21111:7-2--- <br /> Payment Type Invoice# / Check# Recei ed By: <br /> EHD 48-02-025 l"'" r�i TCR M A4 , SR FORM(Golden Rod) <br /> REVISED 11117/2003 1 <br /> S <br />