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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> E 59Lb'w2A61 — <br /> OWNER/OPERATOR <br /> CHECK IF BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> j FC t .S% Street Number Street Name <br /> CITY �, STATE A ZIP <br /> J7 <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 ESL BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS 0 <br /> BUSINESS NAME PHONE# Ezr. <br /> ;Z/-2c i/ Z 2 .6 70 <br /> HOME or MAILING ADDRESS FAX# <br /> 4 —5?4 ( 1 <br /> CITY 1G.G,� O� STATE 6,4 ZIP G�20 <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 /> COLtNTY Ordinance Codes,Standards,STA-!550,5Efl laws. <br /> APPLICANT'S SIGNATURE�j� DATE: <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLLCANT is not the BILLING 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 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. (( .i. <br /> 1 <br /> TYPE OF SERVICE REQUESTED: V3 J'P CU- C6V- V jt n52 <br /> COMMENTS: <br /> C� avq 0 � � JASAN JTY <br /> ENHEALNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNEDTO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: C PIE: V <br /> Fee Amount: ICJ _ Amount Paid l _ Payment Date 02 S , �' ?) <br /> Payment Type S f Invoice# CFjac ct'# J 5 l a s g- Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />