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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 4)tett,�/LCL4. \000 <br /> ^71 59-006 -7 0I; <br /> OWNER/OPE TORI CHECK If BILLING ADDRESS❑FACILITY NAME Il M l I Loll <br /> SITEADDRESS <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME o'r MAILING <br /> GADD]R FESS (If Different from Site Address) <br /> 111`x) V L'�L `ate 41�� � Street Number "' Street Name <br /> CITY_ STATE zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 234- 07.0 - 04 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> clo 5; <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY 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 <br /> or activity will be billed to we 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,STATE and FEDERAL laws. 7 <br /> APPLICANT'S SIGNATURE: k y ud--, DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/NIAINAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT 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 aitd at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Rovof cou4+ <br /> COMMENTS: <br /> 6�l Lw �ti,NLI/ SAAt N 0 '9'y 3 Z��¢ <br /> HFq�T0 0O <br /> 40)" <br /> R Coll, <br /> TMFNT <br /> ACCEPTED BY: EMPLOYEE#: O DATE: <br /> ASSIGNED TO: I w EMPLOYEE#: ' (--?,o DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 0(' J PI E: <br /> Fee Amount:, Amount Paid �v� Payment Date <br /> Payment Type Invoice# Check# 1l Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />