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rIJUA) <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> r=cDoCL -rricy— :: f <br /> Sit c)gS102 <br /> OWNER/OPERATOR <br /> i CHECK If BILLING ADDRESS <br /> FACILITY NAMF IJ <br /> • C �f <br /> SITE ADDRESS r'c.i �•�-V-C S•t' q S Z�{G <br /> l:7 • Street Number Direction Street Name t City 4Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name - <br /> CITY STATE ZIP <br /> CA CAt q 5 10 <br /> PHONE41 Exr• APN# LAND USE APPLICATION# <br /> IQ G -7- - <br /> PHONER Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> So <br /> HOME or MAILING ADDRESS FAX# <br /> -.) ( ) <br /> CITY r CA CA <br /> STATE C ZIP S <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, <br /> �STATE and FEDERAL laws. I <br /> APPLICANT'S SIGNATURE:&996k <br /> i DATE: — —Z2 <br /> e '"1 L4 <br /> PROPERTY/BUSINESS OWNER 3— OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> I'APPLICANT is not the BILLING PARTY proofofauthorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: 'Mien 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: � ^ EMPLOYEE#: DATE: V L <br /> Date Service Competed (if already completed): I SERVICE CODE: I PIE: Z <br /> Fee Amount: 5 Amount Paid (5a Payment Date S 2 Z <br /> Payment Type Invoice# 7 Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> P'Ro�11(al� S <br />