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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 <br /> I � CHECK if BILLING ADDRESS <br /> FACILITY NA �.'v��a�'�c�zr <br /> SITE ADDRESS I V� G JVviu G/it`–� �1�,'c V� 0162, <br /> Street Number I Di,.,Ion Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> 0AN �2(� <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQ TOR• <br /> v��vu L`CSIs 7D ur E l� <br /> BUSINESS NAME � CHECK If BILLING ADDRESS <br /> t(✓Q.IA� �,/ ll� PH _7 E,, <br /> HOME or MAILING ADDRESS FAX# <br /> CITY c 7 STATEl 'n ZIP 01 r� <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 nworoe performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar , TA E and p5bWL la 7, <br /> APPLICANT'S SIGNATURE: DATE: J�J <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT - oc <br /> If APPLICANT 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. <br /> TYPE OF SERVICE REQUESTED: tnc7/n�� . �/�1+7�L2/w{'tE� �/'- (—�/^ r r4 �p <br /> COMMENTS: K �L iq �' 1 �r r t ( 1 ��L� �l.�r!�' Y� "IN (10;0 '•I <br /> ENVOAQI) Z <br /> ACCEPTED BY: EMPLOYEE#: DATE: —0, — <br /> %t (�lL� ✓5 C.�l <br /> ASSIGNED TO: L 1 S rjEMPLOYEE#: DATE: 1r 3 <br /> Date Service Completed (if already completed): SERVICE CODE: ,4_ P 1 E: <br /> Fee Amount: �_ — Amount Paid I — Payment Date 2 <br /> Payment Type �I Invoice# Q Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />