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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 /> CHECK If BILLING ADDRESS <br /> FACILITY NAME i1 �/�`�J•(, <br /> SITE ADDRESS �j �/� Tom-' <br /> 21 � `''Street Number Direction �r ,_' St)1;11 me —1 v�Ci Zi Code <br /> HOME or MAI ING ADDRESS If Different from Site Address) <br /> Street Number Street Name <br /> CITY� STA TE Zip <br /> PHONE#1 ExT. APN# LAND U E APPLICATION# <br /> W1-q) '��� <br /> PHONE#2 ExT. EMAIL BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 1Ae- <br /> -7 CHECK if BILLING ADDRESS <br /> BUSINESS NAME �t \����i ( V^ PHONE# C,I� • &5 5 % EXT. <br /> HOME or MAILII�NG ADDRESS,[ \, j V , FAX# <br /> 37o( Dj-r ( ) <br /> CITY STATE EMAIL�inG1�iV1 C,4 <br /> zlp ns 2OCSk nGt Icon Z LI 0, <br /> , <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 or activity <br /> will be billed to me or my business as identified on this form. <br /> also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JQAQUIM <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE DATE: <br /> PROPERTY/BUSINESS OWNERO OPERATJ I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT it 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 above site <br /> address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the Same time it is provided to me or myi <br /> representative, n CA 1 I(fi1n PA <br /> TYPE OF SERVICE REQUESTED: w y A0 Co 11S u <br /> COMMENTS: I?Z66 NT <br /> RAR <br /> !� J ? <br /> SAN JOAQU! 024 <br /> v yIRONMC OIJIV7 , <br /> ACCEPTED BY: V 1 I EMPLOYEE#: q z� I DATE: T �ZLf <br /> ASSIGNED TO: CVI�/a In EMPLOYEE#: DATE: 3 �! Cj 2-4 <br /> Date Service Completed (if already completed): SERVICE CODE: O( I PIE: LI 103 <br /> 0 J <br /> Fee Amount: I Z Amount Paid o Payment Date <br /> [' <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 03122123 <br />