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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> :googG-740 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITYNAME A-5��-�c� <br /> SITE ADDRESS Number p� VOCAINe S1lCty <br /> Street <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 112331 d 15 Ja2 01 Street Number /e- Street Name <br /> CITY( / 6ro e STATEcf4 zip SSS <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> ( JL )ail - sS <br /> PHONE#2 Exr' BOS DISTRICT LocATlox CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEn' <br /> HOME or MAILING AD RESS FAX# <br /> 12331 0k, (] 1,00, ( ) <br /> CITY e/ STATE A zip q575 <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,Stat:d°(I'ds,STATE and FEDERAL laws. (� <br /> APPLICANT'S SIGNATUIRE/: .j e (�(Q(,� "1�1 DATE: -1' Z-7-0 Z Z- <br /> PROPERTY/BUSINESS OWNERCJ( yO`PERATOR/N111 ❑ OTHER AuT HORIzED AGENT❑ <br /> IJAPPLICANT is not the BLLLtNC PARTY,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 environmemal/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: <br /> COMMENTS: <br /> ACCEPTED BY: I EMPLOYEE#: DATE: 2 �� <br /> ASSIGNED TO: SV ba EMPLOYEE#: DATE: Z 2Z <br /> Date Service Completed (If already completed): SERVICE CODE: P"E: Q 3 <br /> Fee Amount: " OU Amount Paid l7„ ,� Payment Date Gr 2 22 <br /> Payment Type o orInvoice# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />