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SAN JOAQUIN COUNTY ENVH2ONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQU ST# <br /> S�anslg <br /> WNERI OPERATOR <br /> 1 CHECK If BILLING ADORE55 <br /> a <br /> v <br /> FACILITY NAME t r <br /> c t JA-et <br /> SITE ADDRESS �0 Q l/�I �j� ,{" C <br /> Slroet Number Dlreetlon �1 �'SS l Bt Nama 1 <br /> HOME or MAILING`ADIDI1ESS (If Different from Site Address) f1 I <br /> V V � VVI V 1 treat Number Street No - — <br /> CITEI STATE Z <br /> S } o S <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 6 y <br /> PHONE#2 Ex. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> EQUESTOR <br /> CHECK If BILLING ADDRESS <br /> 1 <br /> BUSINESS NAMEt( PHONE# t BT, <br /> I 't t C <br /> 1 <br /> HOME or MAILING ADDRESS V t "A \ 1 (AX# ) <br /> CITY U \ STATE ZIP C 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,STA E andFEDERAL la s. <br /> APPLICANT'S SIGN AT `Grryt_ DATE; <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGERAn OTHER AORIZED AGENT❑ <br /> If APPLICANT 1s not the BILLIArGPARTY proof of authorization io 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 JOAQUrN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it IS available and at th e a it IS <br /> provided to me or my representative. �N <br /> TYPE OF SERVICE REQUESTED: Q <br /> COMMENTS: en'. <br /> JOAO <br /> Ci nu, <br /> it, ���M"�IM4� <br /> NT <br /> ACCEPTED BY: , Ef V, L EMPLOYEE#: DATE: —25`72-Z <br /> ASSIGNED TO: 9 ! EMPLOYEE#; DATE: ` <br /> Date Service Completed (if already completed): SERVICE CODE: nW PIE: UP03 <br /> Fee Amount: -� Amount Pal ( Payment Date 2 2 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />