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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH IOLPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> i <br /> OWNERPE TO ' <br /> y% h CHECK If BILLING ADDRESS <br /> V)l1 <br /> FACILITY NAME <br /> SITE ADDRESS Qc, Chtr tte- QJb <br /> Street Number Direction Street Name ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) _".f �/_ � Ch ro 0,C1 <br /> Street Num—hoer Street Name <br /> CITY . STATE C1 <br /> 4 ZIP q J � <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> -0d <br /> PHONE#2 Err. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR. <br /> Mo � � Nou � CHECK If BILLING ADDRESS <br /> BUSINESS NAME PH NE EST <br /> Jca La y 16)co <br /> HOME or MAILING ADDRESS FAX# <br /> TD)co �. ( ) Cad <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 an aws. <br /> APPLICANT'S SIGNATURE: DATE: 3 ?,q <br /> o q <br /> PROPERTY/BUSINESS OWNER NAGER OTHER AUTHORIZED AGENT❑ ;I <br /> If fIPPLIC 2NT is not the BA —4--- <br /> G P 1 TY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFO ATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the lease of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY NVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. f <br /> TYPE RF SERVICE REQUESTED: ': " " <br /> P�•� ,� +0 ex Is f V eft- fi � no Zzl r <br /> mal tiettR <br /> LSO naZz1es, CLA H lcxL'J c s , t� <br /> 24� P2 7tl�U9 <br /> P4 PoM�N--VtAo Eh1U4RCN �j HA TK <br /> SPE iinre <br /> �*t'*PTpp D BY: EMPLOYEE# ATE; <br /> H ASSIGNED TO: EMPLOYEE#: , 7/� DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I P J E: <br /> Fee Amount: v.� Amount Paid Payme t Date T� U <br /> T <br /> Payment Type Invoice# Check# �� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />