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SAN JOAQI�COUNTY ENVIRONMENTAL HEALTI PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> G(35 k- 4 000 '3'Kil� I <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> FACILITY NAMEI <br /> ll�•cam' ' ,.,,,�,` <br /> SITE ADDRESS <br /> Street Number DlrecDon Street Name 21 Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CIT, STATE ZIP <br /> PHONE#1 E�' APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EM. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR t" ; — I CHECK If BILLING AODRES <br /> BUSINESS NAM\V/ <br /> C <br /> HOME or AILING ADDRESS FAX# <br /> VS.a • '(SM co 60-1 (--e-) <br /> Cm STATE i.(\ ZIP r7 <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,Standar` STATE and FEDERAL laws. / <br /> APPLICANT'S SIGNATURE:�u////1/✓1/G� n7 - DATE: �3 <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLIC4NT 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 environmentaUsite assessment <br /> information to the SAN JoAQuiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available an eWsame time it is <br /> provided to me or my representative. Rei\ICD <br /> TYPE OF SERVICE REQUESTED: ,5 / <br /> COMMENTS: MA T`I <br /> SPN NV RoNMT t`{T <br /> N -(H DEPQAR <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: - EMPLOYEE#: < 2 �' DATE: <br /> Date Service Completed (H already Completed): SERVICE CODE: PIE: 06 <br /> Fee Amount: Amount Paid 06'7 q a Payment Date $ d O <br /> Payment Type �. Invoice# Check# Ll <br /> Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />