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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVIft REQUES <br /> Type of Busi ss or Property FACILITY ID# S RVICE REQUEST# <br /> OWNER/O RATOR r <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME p� <br /> SITE ADDRESS /Ll g'�I � <br /> Street Number Diition r Nam e...lYq�OA Ci ZI Code <br /> HOME or MAILING ADDRES (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE# APN# /T, ®O LAND USE APPLICATION# <br /> PHONE#2 ExT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> R U -Kr/--&331�z <br /> HOME or MAILIN ADDRESS FAx# <br /> 1146/-& <br /> CITY L,^ ' 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 this appl' IItion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, S AT,�and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: � / DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT V^ <br /> IfAPPL1CANT is not the BrttrNc PAR 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. <br /> TYPE OF SERVICE REQUESTED: SUED <br /> COMMENTS: <br /> SEP 15 2o0n <br /> SAN JOAQUIN COUNTY <br /> ENNRONMENTAL <br /> I/ HEALTH DEPART <br /> TMEN <br /> ACCEPTED BY: EMPLOYEE#: 7 DATE: <br /> ASSIGNEDTO: EMPLOYEE#: Z ( / DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I P 1 E: <br /> Fee Amount: / Amount Paid a$ S Payment Date OI lS A <br /> Payment Type L/ Invoice# Check# `�� Received By: NCr <br /> EHD 25 SR FORM(Golden Rod) <br /> REVISEDSED 11 11/17/2003 <br />