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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 1 OPERATOR <br /> r 4 rfOSL5. <br /> CHECK If BILLING ADDRESS <br /> FAOILI NAME <br /> SITE ADDRESS p O C l(S-`c V t�0 y Y\t Ck <br /> StreelJJNumber Dir`ecJdon Street Name •J `J Cit .1 Zip Cotle `J <br /> HOME Or MAILI G AD/D'RESS 1(If Different from Site Address) <br /> -I LI `U 11'T Street Number Street Name <br /> CITY STATE ZIP <br /> -). A q S 2G <br /> PFP" . Ear. APN# LAND USE APPLICATION# <br /> (20p) _qyq 03 I- <br /> PHONE#2 Ezr. BOS DISTRICT LOCATION CODE <br /> l ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR p <br /> '� f R� I- CHECK CHECK If BILLING ADDRESS <br /> BUSINESS NAME i E'm' <br /> El i 1 L)L-I I <br /> HOME or MAII ING ADDRESS FAX# <br /> �4 -IG 1 WCAV 1 ( l <br /> CITY STATE ZI 2 Q <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 /> C.OttNTY 0ldiwmee Co<(es,Standards,STATE and F ERAL laws. [� // <br /> APPLICANT'S SIGNATURE: DATE: C�Qi k <br /> PROPERTY/BUSINESS OWNER❑ OPE TOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> IJAPPLICANT Is not the Bl LING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1, 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. <br /> TYPE OF SERVICE REQUESTED: ENT <br /> COMMENTS: FD <br /> AUG 08 <br /> qJO 202022�RD UlN CO <br /> e C w�l�h( WF,fO pARAL <br /> ACCEPT OBY: EMPLOYEE#: DATE: <br /> ASSIGNEDTO: EMPLOYEE#: q11 q <br /> DATE: �fjy <br /> Date Service Comp eted (if already completed): SERVICE CDo : 0 P 1 E: I U3 <br /> Fee Amount: •U 0 1 <br /> Amount Paid f'r5(Q Payment Date n - & <br /> Payment Type Invoice# tBDb Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />