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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPEjtATOR v <br /> i5 / C O CHECK 1f BILLING AODRESS� <br /> FACILITY NAME0-4 cp CA In de <br /> B e4 l <br /> SITE ADDRESS <br /> root Number I Direction .V Street Nam. u. <br /> r.k1l ME.OrMAILING ADDRESS (If Different from Site Address) <br /> , <br /> ^-'Il Laramic w5 Q Street Number C(A-t Name <br /> .CITY S ko ck Q $TAT ZIP tQ d q <br /> PHONE#1 EST• APN# LAND USE APPLICATION# <br /> PHONE#2 EST. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTO CHECK If BILLING ADDRESS <br /> BUSINESS NAME IF/ <br /> 2 ( PHONE# E"T• <br /> HOME or MAILING(JADDRESS� l / FAX# <br /> 6 ( QMt It w(ZL( ( ) <br /> CITY !SAO / I STATECa ZIP C O C/ <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 at ERAL IawS. �1 <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPE . It ANAGER ❑ OTHER AUTHmuzEDAGENT'❑ <br /> IfAPPLicAAT is not the BILLING PAR 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. AA <br /> TYPE OF SERVICE REQUESTED: r �, � R A <br /> COMMENTS: j <br /> MAY 09 <br /> 4'JoA 102? <br /> HFNhRQ1INC <br /> ThDEHT,v 7y <br /> ACCEPTED BY: EMPLOYEE#: DATE: 5 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: O P/E: <br /> Fee Amount: ,/ Amount Pa 152,oD I Payment Date <br /> Payment Type Invoice# Check# Recei ed By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />