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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Bu ' ess or Prope FACILITY ID# <br /> W SERVICE REQUEST# <br /> DDS S <br /> OWNER/OP RATOR CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS JJqq �/}� /, 1` ,/]/� ✓/y'/�y//��///W/// G�'� <br /> 1• L6trEet Number Direction `-CSGeetN �� �i ZI Code <br /> HOME or MAILING ADD S (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 E�• APN# LAND USE APPLICATION# <br /> (2q 'a 39 -a717 <br /> PHONER Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I '/ CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHO f <br /> i1 <br /> HOME or MAILING ADD SS F <br /> CITY - STATE zip <br /> BILLING ACKNOWL GEMENT: 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 this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA and FEDERAL laws. /p <br /> APPLICANT'S SIGNATURE: LQ t ll l��61 -- DATE: V <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Q u <br /> IfAPPLICANT 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availal and a e srame time it is <br /> provided to me or my representative. f� �V� <br /> TYPE OF SERVICE REQUESTED: _ <br /> COMMENTS: SAA' pu /NOOUNTy <br /> yFEWLrHb PA M Nr <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: 2 °Q Amount Paid Q Payment Date <br /> Payment Type Invoice# Check# I. 2 b I Received By. N <br /> EHD 40-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />