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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> Moo g�a <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction t Name city Zip Code <br /> HOME or MAILING ADDRESS (If Dtfferent from Site Address) Z) w' <br /> reef Number tree N m0 PA <br /> ]► <br /> CIN � Alisb� STATE �,,. ZIP, �S�Cn <br /> PHONE#1 ExT —AP N,# LAND USE APPLICATION# l• QED <br /> ( ) O r EB 1021 <br /> PHONE#Z ExT• BOS DISTRICT LOCAQI <br /> ( ) RUIN T L <br /> CONTRACTOR/ SERVICE REQUESTOR L FH DEPARTh ENT <br /> REQUESTOR <br /> r� CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT, <br /> I J e rl r �♦ I xoL `q <br /> HOME or MAILING ADDRESS FAx# <br /> CITY Is r -I STATE �� ZIP �j <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 ENVIRONMEv rAL 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 plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ATE and FE L laws. <br /> APPLICANT'S SIGNATURE: DATE: (I^i �� I/Z C Z Z <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT�%eLh Df V ed j4-)m eot L c!oJ <br /> If APPLIC4.NT is not the BILLING PAR Ty.proof of authorization to sign is required Tihe <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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> z A11W 7�' Scaurtr4-c- © � Uovr7 T�\ L4 oAlto wrorr 0� , <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ': P/E: <br /> Fee Amount: p Amount Pai , Ud Payment Date 2 <br /> Payment Type Invoice# Check# / Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />