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Cw SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> V5 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME v <br /> SITE ADDRESS <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME Or MAILING ADDRES (If Different from Site Address) <br /> 4) n % it Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 Exr• APN# LAND USE APPLICATION# <br /> (coq,)22 S- —MCLS <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR - <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Err. <br /> b � \ 051 )ZZS - 19otS <br /> HOME:pr MAILING ADDRESS FAX# <br /> CITY C� STATE zip �52� <br /> BILIANG 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, d FEDERAL laws. nn <br /> APPLICANT'S SIGNATURE: DATE: I v �/ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGEROTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is not the B=WGPARTY.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. AftA <br /> ly <br /> Abt�m <br /> TYPE OF SERVICE REQUESTED: ,°r�,tl��0 <br /> VA <br /> COMMENTS: <br /> ! <br /> yRfZ ON/N7COU�THCfPgRTTA( ry <br /> NT <br /> ACCEPTED BY: an a EMPLOYEE#: F D DATE: O (� <br /> ASSId61370: - EMPLOYEE#: 1 //�I DATE: 10 <br /> Date Service Completed (if already completed): SERVICE CODE:53 P I E: '�O <br /> y�,� u <br /> Fee Amou t. L e� w..'1 Amount Pal S/ �� Payment Date /,L.�/� <br /> Payment Type xInvoice# Check# 133 22.E /-9 l -7 Receive/d Byl <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISE-D 11/17/2003 <br />