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M SAN JOAQUIN ' -IUN'1'Y k NVIRONMENTAL I EALTH ' "'PARTNIENT <br /> SERVICE REQUEST - <br /> T pe of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S Dnp T-7 3 <br /> OWNER/OPERATOR <br /> --F•NECKILBILLING ADDRESS <br /> FAcILfTY NAME L tfall A <br /> SITE ADDRESS ' ���yN�- ��, �—,✓--� -�G� � �.�-� S <br /> 7 Street Number Direction 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 ExT. APN# LAND USE APPLICATION# <br /> > --1--(! L-`Z:a <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> i CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> ( ) <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 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 FTATE <br /> ion a that the w rk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, and F ERAL law <br /> APPLICANT'S SIGNA DATE: 1 �° <br /> PROPERTY/BUSINESS OWNER OPERATOR/NIANAGER ❑ OTHER AUTHORIZED AGENT❑ ^ <br /> If APPLIC.4Is not the BILGING 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 environm site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available ane it is <br /> provided to me or my representative. /,' <br /> TYPE OF SERVICE REQUESTED: CQ/\J S c t L-T7�TZ v� LL( Lt t 13 y ,( <br /> COMMENTS: JOA�UIiy <br /> c�`�' `�S3-76 q 7 " tioFP E �^' ' <br /> ACCEPTED BY: D(� V�G�p EM>LOYEE#: 0 DATE ff Q <br /> ASSIGNED TO: �S C-10-CFDEMPLOYEE#: S- C DATE (� Q <br /> Date Service Completed (if already completed): SERVICE CODE. �(o PIE: <br /> �2 Z <br /> Fee Amount: CI 3 .p Amount Paid Payment Date ep <br /> Payment Type Invoice# Check# 0-6 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />