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SAN JOAQUIN OUNTY ENVIRONMENTAL HEALTH DE RTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �Do01�� �v S os <br /> OWNER 1 OPERATOR A6 CHECK If BILLING ADDRESS <br /> F { <br /> CIUTY NAME ~'1 <br /> SITE ADDRESS � �C ��ys [} r �'g�OCA4 <br /> �� h� <br /> Streatet7Number Direction � l StreetNamFe1vo City <br /> VOIVVE Or MAILING ADDRESS (If Different from Site Address) ail z–LJ <br /> Si0�d <br /> Street Name <br /> CITY STATE ZIP <br /> PHONE.#1 EXT. APN# LAND USE APPLICATION# <br /> (201) °ISI �65g <br /> PHONE#2— EXT• BCS DISTRICT LoCAT10N CODE <br /> CONTRACTOR 1 SERVICE REQUESTOIR` <br /> REGIUESTOR <br /> S/J(/l[J & CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT• <br /> { <br /> HOME Or MAILING ADDRESS FAx# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGE rA ENT: 1, 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 e work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standar�STE F ERAL <br /> APPLlt.ANT`S SIGNAT UR DATE: <br /> PROPERTY I BUSINESS OWNEro OPE ATOR I ER ❑ OTHER AUTHORIZED AGENT ❑ _ <br /> If APPL1CAN7 is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any anis all results, gootechnical data and/or environmentallsite assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided t0 me or <br /> my representative. <br /> TYPE OF SERV[ wj <br /> CE REQUESTED: Ir <br /> COMMENTS: RECEIVED <br /> AUG o 4 NA6 <br /> SAN JOAQUItd COUNTY <br /> EptVl DEPAATM"T. <br /> ACCEPTED BY: EMPLOYEE M <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Complet4suif already comrrl ed): SERVICE CODE: LV PIE <br /> Fee Amount: _ Amount Paid Payment(Date <br /> Payment Type Invoice* Check# a,4 --7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07117!08 <br />