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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 06/ V16-c- Z�3 <� 06g50�G <br /> OWNER/OPERATOR <br /> 2� / CHECK If BILLING ADDRESS <br /> FACILITY NAME L <br /> SITE ADDRESS �.i if /�UY(�.�LU 47-3 s/0c�4111- /d <br /> Street Number Direction Street Name city ZIP Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 4.J / Street Number - J Street Name -1 - <br /> C ft,G STATE ZIP <br /> I{— <br /> dI 2 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (20q ) SgY- 6f IS <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ ERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE �y� L/ 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,Standa and FERE <br /> APPLICANT SIGNATURE: ATE: <br /> PROPERTY/B SI�OWNER❑ OPCRATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> Jf�APPLICANT is not elle BLLLLNGPARTP proof of authorization t0 sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,I, the owner or operator of the prop ated at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environme s t <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and i is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: p, <br /> COMMENTS: HZiM i OUNry <br /> �D��FN7' <br /> ACCEPTED BY: C / fes. EMPLOYEE#: DATE: <br /> ASSIGNED TO: Yt't l�„e -� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ✓PIE: �GU� <br /> Fee Amount: Amount Paid '(�'d_ Payment Date '312112 Z <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> p�za 1��538" <br />