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t SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE RdEQQUjEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Ir f l I Tc1 G <br /> TE <br /> DRESS-TDMA"SSa' //� �t� ! /,r /✓/7/f /) <br /> 0 Street Number DirecS t et Name e tion �/ -`t - Zip Code <br /> HOME or MAIN D E (If Different from Site Address) I,p^i <br /> i Street Number l treat Nam <br /> CITY STATE IP 6 <br /> PHONE#I C' cS / ExT. APN# LAND USE APPLICATION <br /> l # <br /> (20 ) (0 I— � b I <br /> PHONE#2 Ez. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR / CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE n /.� /^ iEE <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <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 /> 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: J Q 5 US /Z d /J ��� DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> IfAPPLtCANT is not theBLLL/NGPARTP 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 aF jlne it is <br /> provided to me or my representative. gle <br /> Nr <br /> TYPE OF SERVICE REQUESTED: VaLl <br /> COMMENTS: Udr2022 <br /> SAN <br /> ENVIRON N COUArry <br /> HEALTH DEA4TMA <br /> ACCEPTED BY: I q ��/ EMPLOYEE* lA V7 6 <br /> DATE: (] <br /> ASSIGNED TO: "l u"I EMPLOYEE#: 111 ' DATE: !/7 r)- <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: I l! <br /> Fee Amount: 1 OV Amount Paid 5a: Payment Date I 8 2 2 <br /> Payment Type Invoice# Check# Received By: utrlK <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 � 0'52-(Po <br />