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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> c� 3 3S <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS ?SO W � <br /> Streel Number Direction v - Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ezi. APN# LAND USE PLICATION# <br /> ( ) <br /> 4 3 6/ �Gl <br /> PHONE#2 EXT' BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQU ESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> �`�. s - � o Sa - <br /> HOME Or MAILING ADDRESS FAx# <br /> /0 '�' Sf (�v A s I/ - 90 S- <br /> CITY STATE /' _ ZIP S c ^Z a <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 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. <br /> APPLICANT'S SIGNATURE: DATE: !Z�/a/D 3 <br /> PROPERTY/ BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> If APPLICANT iS not rhe 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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentallsite 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. ENT <br /> TYPE OF SERVICE REQUESTED: RECE) <br /> COMMENTS' <br /> )Z�u7 7 31/a-0ro3 DEC 10 200 <br /> �� &J( SAN Ny RONIMEN AL <br /> TM <br /> UsP.O.EpI. J pV HATH DEPARTMENT <br /> �QDM.w tr't�-0' <br /> 17 <br /> ACCEPTED BY: EMPLOYEE#: 576 DATE: / �O 0 <br /> ASSIGNED TO: EMPLOYEE#: 14 <br /> DATE: I <br /> Date Service Comple ed (if alread completed): SERVICE CODE: PIE: d'G <br /> Fee Amount: Amount Paid Payment Date <br /> 92 <br /> Payment Type Invoice# - Check# Received By: <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />