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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Skip 5 � <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS Ll <br /> FACILITY n1a, - of LL(. <br /> 2a0(�ss F— �t•Y�tt� S{Or✓ktov� 45z�� <br /> Street Number Direction tree[NIUOIJame CI ZI Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY ST TE ZIP <br /> S ave Jo�'-e- 9 S I <br /> PHONE#1 Exr' APN# LAND USE APPLICATION# <br /> (A010 `l -OI22U <br /> PHONE#2 Exr• BOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> SCr• �A�yi CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> HOME or MAILING ADDRESS FAx# <br /> ( I <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> Iacknowledge 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 d F law . <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When 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 environmentee ssseessment <br /> Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at Ts <br /> provided to me or my representative. RECEIVED <br /> TYPE OF SERVICE REQUESTED: <br /> NOV 0 1 2M- <br /> COMMENTS: <br /> SAN JOAQUIN COUNT <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> L' +� <br /> ACCEPTED BY: � MAN EMPLOYEE M DATE: I ( 1 ;-:7 <br /> ASSIGNED TO: EMPLOYEE#: a qVg DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/ <br /> Fee Amount �'w Amount Paid pt `S� _ Payment Date ' 1 [ vV Z 2— <br /> Payment <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />