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SAN JOAQUI' AUNTY ENVIRONMENTAL HEALTH ;PARTMENT <br /> SERVICE REQUEST <br /> Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ OPERATOR / <br /> /�—J( CHECK If BILLING ADDRESS <br /> i <br /> FACILITY NAME (W_ <br /> J <br /> �A� n <br /> SITE ADDRESS _� JO <br /> S eet Number tonH /St ame �/( it Zi Code <br /> HOME Or MAILING A SS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#I EXT' APN# LAND USE APPLICATION# <br /> ( 0q <br /> F <br /> NE EXT. rISTRICT LOCATI N CODE <br /> ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRES <br /> BUSINESS NANRESS <br /> Exr. <br /> HOME or MAI / // F,Arx##�Q /q' ` 2 L <br /> I� e//I R 1—C! 31 <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared th' a plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,StandaCornl&_/ <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTP (/ <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. !94 <br /> TYPE OF SERVICE REQUESTED: l�S � (� C�JV T <br /> COMMENTS: 200,9 <br /> SM/�O <br /> h' E47 'J//V C <br /> �C per" <br /> ACCEPTED BY: C-, EMPLOYEE#: © DATE: 2.S <br /> ASSIGNED TO: C)6v C,— EMPLOYEE#: fl? DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: 19e- P I E:22,3og` <br /> Fee Amount: 31�5`0� Amount Paid 31�S _ Payment Date g 10 <br /> Payment Type V/' Invoice# Check# 144 c5lc Received By: <br /> EHD 48-02-025R'FOFtl31;(Golaeli Ftoii)"` <br /> REVISED 11/17/2003 <br />