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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQ ES # <br /> J <br /> PWNER/OPERATOR <br /> CHECK if BILLING ADDRESS O <br /> F m NAME <br /> e ��1 a✓� <br /> SITE ADDRESS ��. C <br /> `' `.� <br /> c � Street Number Direction a' Street Name city zip Code <br /> HOME or^MAILING ADDRESS (If Different from Site Address) <br /> QV u� Ck I o Street Number Street Name <br /> CITY SCATF� ZIP Ll <br /> t{} t <br /> PHONE#1 E". APN# LAND USE APPLICATION# <br /> (2ccI) aIu -1ball, <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> QUEC`QR CHECK If BILLING ADDRESS <br /> INESS NAME PHONE# E". <br /> 2 is ( 1 <br /> HOME Or MAILING ADDR S FAx# <br /> CI STATE ZIP ` !7 t Z <br /> c V '1 <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. Q <br /> APPLICANT'S SIGNATURE: l /19+ DATE: <br /> �^ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IJ'APPLICANT is not the BILLING PAR TY 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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: RECEIVE <br /> COMMENTS: NOV 19 20 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENT <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: l <br /> ASSIGNED TO: EMPLOYEE#: DATE: r <br /> Date Service Completed (if already completed): SERVICE CODE: D PIE: O <br /> Fee Amount: Amount Paid S 2 Payment Date 11/Z2 <br /> Payment Type Invoice# Check# 77- Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> p�v�3S� <br />