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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 OPERATOR V� _ ?E3?IE3 if ILLI GADDRESS® <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Dilon �/ Seddt ame ✓ / • ZI Cade <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> 6 51= Street Number Street Name <br /> CITY _ STATE ZIP <br /> O C <br /> PHONE#1 Ezc APN# LANb USE APPLICATION# <br /> PHONE#2 En. - BOS DISTRICT LOCATION CODE <br /> ( i <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTORT / t-- C` , CHECK If BILLING ADDRES� " <br /> �G <br /> BUSINESS NAME. PHO E# En. <br /> a <br /> HOME or MAILING ADD ESS FAx# <br /> CITY r STATE zip <br /> B11JANG 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: (�Cet� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 V <br /> If APPLICANT is not the BILLING PAR TP 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.l(t 1 p� <br /> TYPE OF SERVICE REQUESTED: o l" l o rPlr <br /> COMMENTS: /�i_f, rl � <br /> �� <br /> Iv�rll`l/b V ` 1 Iy ry C <br /> H � pq FNTAC 7 y <br /> ACCEPTED BY: EMPLOYEE#: DATE: T <br /> ASSIGNED TO: L� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �' P I E: 1,(V8 <br /> Fee Amount: SI.Q Amount P3` . 00 Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02.025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 wA <br />