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SAN JOAQ, COUNTY ENVIRONMENTAL HEALTH oEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> _! C_LA N �j CHECK If BILLING ADDRESS <br /> e1LIVN <br /> TYNAME, 6G �AaS _ JUS ti 1 r\C <br /> SITE DRESS CI-Q 1qa e MO � <br /> Street Number Direction Street Name Cit Zip Code <br /> H ME or MAILING ADDRESS (If Different from Site Address) <br /> 1 �(�\< C ` 7 L �� Street Number Street Name <br /> C TY STATE ZIP <br /> PHONE#1 ExT. API# LAND USE APPLICATION# <br /> > L-1 Os 0 v <br /> ONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEST0,R n 1 o CHECK if BILLING ADDRESS <br /> BUSINESS NAME 's L\ L� PHONE# C� EXT. O� <br /> Mei9fE or MAILING ADDRESSAx r� -?3 0 � � t � Ct � ( # ) <br /> CITY SCAB C'sC - 1 C.N STATE 19 ZIP 9 I-D JID <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 wo k to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STAT 7 and FEDERAL laws <br /> APPLICANT'S SIGNATURE ~" DATE: L 0 2 <br /> PROPERTY/BUSINESS OWNER2r OPERATOR/M AGE ❑ OTHER AUTHORIZED AGENT❑ <br /> ifAPPLIC.9T 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. <br /> TYPE OF SERVICE REQUESTED: 6-e S 7 D/ui g u <br /> COMMENTS: <br /> oPPONQ �N� <br /> ACCEPTED BY: CD Com.) EMPLOYEE#: <br /> ASSIGNED TO: U G EMPLOYEE#: C �/ DATE: Z3 / 2_ <br /> Date Service Completed (if already completed): SERVIC CODE: P/E: 2_3 ( <br /> Fee Amount: 1 S �:.� Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 y SR FORM(Golden Rod) <br /> REVISED 11/17/2003 O D <br /> C <br />