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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -IF 'Seoo 691/7/ <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> ba- %Ak I <br /> SITEADDRESS 52� �O�eh2�� �cn 530` <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street NumberT Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> 1 REQUESTOR <br /> REQUESTOR ���^ av� <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME �t15pQ CkL�dV1 PHONE# ExT. <br /> ( <br /> HOME or MAILING AD ` FAX# <br /> S` .- <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,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE:. DATE: <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 enviromnental/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. 1_ <br /> TYPE OF SERVICE REQUESTED: QS (( -�r� S t�-�• <br /> COMMENTS: SQ.CCV^�C�, <br /> `n uw,�ec hoc 55 L �0c cl— OrR-, <br /> a� V-cam,. S'f- kt-� VcaLti <br /> ACCEPTED BY: 1�, ` EMPLOYEE#: bC3O DATE: <br /> ASSIGNED TO: EMPLOYEE#: cl000 <br /> DATE: 2-2,ki-M <br /> Date Service Completed (if already completed): _z Lt— SERVICE CODE: PIE: T <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 / SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />