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SAN JOAQLW-OUNTY ENVIRONMENTAL HEALTIOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> EEi�jj q P-o o-7 --1-�(r <br /> OWNER/OPERATOR <br /> LL <br /> C -T CHECK If BILLING ADDRESS <br /> FACILITY NAME P. I ki(\W�on Lidil �,-We4ca_1, � n I <br /> f 1 <br /> SITE ADDRESS �, 3c) <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 12 OD <br /> Street Number Street Name <br /> CITYS7 TE ZIP �Q <br /> L��1�va S <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (925 ) 00 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 'L; \ <br /> ` `\ CHECK if BILLING ADDRESS <br /> BUSINESS NAME ^ `• PHONE / C�C� EXT. <br /> 2 <br /> HOME or MAILING ADDRESS 3 �4 FAx# ) <br /> CITY CV STATE a ZIP 952—IS <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 ENv1RONMENTAL 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 JOAQMN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLINGPAR7T 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 atAe same time it is <br /> provided to me or my representative. �9 �11F <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: %%'O <br /> Ha .,t� <br /> ACCEPTED BY: EMPLOYEE M g000 DATE: -7/t4h 5 <br /> ASSIGNED TO: ` EMPLOYEE#: 3,91? DATE: -7/7,4// <br /> Date Service Completed (if already completed): SERVICE CODE:522 PIE: <br /> (�Z <br /> Fee Amount: Amount Paid�0� Payment Date 7� 47 <br /> Payment Type Invoice# Check# �� 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />