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SAN JOAQUIN 1UNTY ENVIRONMENTAL HEALTH nEPARTMENT <br /> a SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> Typ:of Business or Property �r� O 0o 2 Z r <br /> t'1 lJ J�JO �� Vu ' <br /> CHECK if BILLING ADDRESS0 <br /> OWNER/ OPERATOR <br /> FACILITY NAME <br /> �� � r��t,�- amici �S�t�cv��� ,� iS� ►L <br /> SITE ADDRESS 1 LZ L1 Ci Zi Code <br /> Street Number Direction <br /> Street Name <br /> "'t <br /> ifferent from Site Address) <br /> HOME or MAILING ADDRESS (if DStreet Name <br /> $freet Number <br /> STATE ZIP <br /> CITY �aG\1 YYl G <br /> ExT. APN# LAND USE APPLICATION# <br /> PHONE#1 <br /> (aocp C C' BOS DISTRICT LOCATION CODE <br /> EXT. <br /> PHONE#2 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> CHECK If BILLING K�-r <br /> REQUESTOR <br /> C.r1 C <br /> PHONE# <br /> BUSINESS NAME + \ � ) , _3 <br /> FAx# ( � <br /> HOME Or MAILING ADDRESSL� ) `1 1 <br /> STATE C� ZIP eT �J�1 cr S — <br /> CITY L <br /> BILLING A1-WNV0 VLEDGEMENT: 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,Standar. s, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: <br /> DATE: 2 Q L, <br /> PROPERTY/BUSINESS OWNER❑ / OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> Y00 O authorization to sign is required Title <br /> If APPLICANT' tot ti <br /> e BILLING PARTY,p f f <br /> AUTHORIZATION TO RELEA E INFORMATION: When applicable, I, the o neor operator of or en the pr <br /> ntallsite erty assedssmeat lnt <br /> above site address, hereby authorize the release of any and all results, geotechnical <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 /> `"t p <br /> TYPE OF SERVICE REQUESTED: (( S'>— v F I <br /> ri <br /> COMMENTS: �A1 ZQO <br /> SAN JOlAQU1tS GOUN I Y <br /> HATH DEPARTMENT <br /> EMPLOYEE#: 032-1 DATE: <br /> ACCEPTED BY: <br /> EMPLOYEE#: 35? D <br /> ASSIGNED TO: <br /> ATE: S ?C• (� <br /> Date Service Completed (if already completed): <br /> SERVICE CODE: I!./?� PIE .23 <br /> F.ee Amount: �-7 c� , L�\J <br /> Amount Paid Payment:Date a0 <br /> t Invoice# Check# eceived�Byy: <br /> Payment Type <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />