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P 9 0,5 V 7'-� (,->& <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />(; 9Z 10®g121 <br />OWNER i OPERATOR A <br />CHECK If BILLING ADDRESS <br />OL <br />FACILITY NAME T-ead�6 / <br />�• .w <br />SITE ADDRESS a02 <br />Street Number <br />� (/t <br />Direction _• Street Name <br />A <br />{/l Cit_J <br />may. <br />✓�Zi/Coderr <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />�O1 q02EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />J <br />'knvla[ a� <br />BUSINESS NAME <br />EXT. <br />P NE <br />Rlcy6l i (A <br />r <br />/ <br />- . <br />HOME or MAILING ADDRES <br />4 <br />FAX # <br />CITY- w STATE % ZIP Q 7 <br />BILLING ACKNOWfEDGEMENT: 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, S E and F ERAL ws. A <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERAVR / MA AGER ❑ OTHER AUTHORIZED AGENT �Q", Q'K.✓ <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. PA I.. s _ <br />p - I IV/ <br />TYPE OF SERVICE REQUESTED: �' O �T ,clT/ <br />COMMENTS: SEP <br />15 202, <br />SAN �OAQUIN CO <br />HEALTH DOE AR ME TY <br />NT <br />ACCEPTED BY: 6 EMPLOYEE #:n DATE: 9 <br />ASSIGNED TO: EMPLOYEE #: 9 83 4 DATE: 9 1 <br />Date Service Completed (if already completed): SERVICE CODE: O P I E: <br />Fee Amount: 1 S Amount �5� v Payment Date /5Z/ <br />Payment Type v�� I Invoice # I Check # l "� /�J I Received By: <br />CoNlr. 1314,33 863 u/ �/� <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />