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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ODD+��s S o I <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME �I V C I�) 4f+0 <br /> IT ADDRESS r <br /> �� <br /> Street Number Direction Street Name City ZIP Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name - <br /> CITY STATE ZIP <br /> PHONE#1 Em APN# LAND USE APPLICATION It <br /> ( ' ) `J <br /> PHONE#2 En. BOB DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �—C' \� p I(1 0 C y <br /> —lJ tiv I IV CHECK If BILLING ADDRESS <br /> BUSINESS NAME KI C Ql11-L O PHONE# Exr• <br /> 5101 2 <br /> HOME orr�MAILING ADD R SS FAX# _ <br /> .h �tlr S T ( 1 ) <br /> CITY STATE C /k ZIP Cf S �J <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. <br /> APPLICANT'S SIGNATURE: CJ DATE: <br /> PROPERTY/BUSINESS OWNER 13 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 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: ItjE Nj` <br /> COMMENTS; APAPR 4 ?0� <br /> aANry CXQIJINCWlN <br /> CacDI,��S�'k HEACTyC PMf�AL n <br /> op <br /> ACCEPTED BY: s, EMPLOYEE#: 30 DATE. <br /> ASSIGNED TO: EMPLOYEE#: ngy DATE: <br /> Date Service Completed (ifalready com leted): SERVICE CODE: /�� PIE:'WU,�_ <br /> Fee Amoun 1q)-'UV Amount Pal OZ) Payment Date 2� <br /> Payment Type � Invoice# Check# I(F l7 ReIceiv dBy: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> ��c5�5"12'I S <br />