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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />PHONE# EXT. <br />SERVICE REQUEST # <br />afro I�si�PSs <br />CITY STATE ZIP <br />ACCEPTED BY: U <br />5R0022(P3 <br />OWNER 1 OPERATOR <br />( / <br />CHECK If BILLING ADDRESS <br />ASSIGNEDTO: CHLO <br />FACILITY NAMEI <br />L. us f l� �e�„�,. <br />li <br />SITE ADDRESS <br />SERVICE CODE: I� <br />PIE: of <br />Fee Amount: t JFi Amount Paid <br />5 2 0 7 <br />Street Number <br />Direction C ' L t Name <br />Check # <br />v <br />ZI Code <br />HOME or MAILING ADDRESS (If Different from Site Address) d -7 a b <br />,(�Ci /� <br />t(J�C e 1 j ''YV If <br />Py <br />Street Number <br />Street Nema <br />TAE ZI <br />CITY S Ir <br />� <br />5 7 <br />Com0 <br />PHONE #i Exr. <br />(zoy) '15 3 v 55 S <br />APN # <br />LAND USE APPLICATION IF <br />PHONE #� EXT. <br />(Zo9i 57 51 <br />BIDS DISTRICT <br />11 <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REOUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE# EXT. <br />HOME or MAILING ADDRESS <br />FAX# <br />CITY STATE ZIP <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, Slandards, STATES d F ERAL s. q <br />APPLICANT'S SIGNATURE: -----J` DA•rE: <br />PROPERTY / BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />IjAPPcrCANT is not the Bn.tlAIc PARTY pronf ojauthorization to sign is required <br />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 die 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 i5 available and at the same time it is <br />nrovided to me or my renresentative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />ACCEPTED BY: U <br />EMPLOYEE#: � <br />DATE: 144t <br />ASSIGNEDTO: CHLO <br />EMPLOYEE III: �;j <br />DATE:' y 'I, <br />Date Service Completed (if already completed): <br />SERVICE CODE: I� <br />PIE: of <br />Fee Amount: t JFi Amount Paid <br />t S Payment Date <br />y <br />y h ZZ <br />Payment Type Invoice # <br />Check # <br />Received By: <br />EHD 4"2-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />