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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTI3 DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ;ERVICE R QUEST# <br /> R l l� SSW <br /> WNER/PPERATO <br /> L ( CHECK It BILLING ADDRESS <br /> AgtrrvNA e � V i,�..�pli I�Q�'Kil CGL✓1 �-l��'i� <br /> SITEADDRESS <br /> Street Number DirIDI Stion Street NamS'�iC ✓itt^'1-e^��'tJ GJL • L°�1 <br /> 01,5zL4t] <br /> ece CI Zip Code <br /> HOME or MAILING ADDRESS (If Differe f om Site Address) <br /> Street Number Street Name - <br /> CI STATE ZIP <br /> PHONE#1 EST APN# LAND USE APPLICATION# <br /> (209 ) zqz 9221 <br /> PHONE#2 ETT. BOB DISTRICT LOCATION CODE <br /> (2 ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> LUSINESS NAME # En. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 1 STATE 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,Standards,STATE 74FEDERAL laws. <br /> APPLICANT'S SIGNATURE: . <br /> �Z <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLiNGPARTP 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 enviromnental/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. P p <br /> TYPE OF SERVICE REQUESTED: (BOG V4 V•t �V�S �fj1'�,(i, ReC <br /> COMMENTS: VV`trllti-�f 0t� rI N 10 <br /> ?0 <br /> k �J�UROAI <br /> UiNCOOIVI <br /> „ T HD <br /> ACCEPTED BY: 7V'� EMPLOYEE#: DATE: <br /> ASSIGNED TO: GT EMPLOYEE#: DATE: V <br /> Date Service Complete (if already completed): SERVICE CODE: PIE: tn�� <br /> Fee Amount: I 2 Amount Paid 15a Payment Date <br /> Payment Type Invoice# 8 N,4 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />