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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 53 <br /> OWNER/OPERATOR <br /> D^ VS t,I�D <br /> FACILITY NAME /t CHECK it BILLING ADDRESS <br /> SITE ADDRESS I57on 1—pD 1 95z4Q <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 4ZSg W 94e—&EJ-JT— P- D <br /> Street Number Street Name <br /> CITY STATE C2—'a ZIP ':�>5 <br /> '�f Z <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 201) 334 IS I+ / a—3� �' F>a _ 0 7 --1--s4¢. <br /> PHONE 92 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR y DI CHECK if BILLING ADDRESS <br /> PHONE# EXT. <br /> BUSINESS NAME <br /> D ( � M.Utt pt4Y 20 3�¢-66 t3 <br /> HOME or MAILING ADDRESS FAx <br /> P.O. 3.A Z18v (� ) 334—o�Z3 <br /> CITY I�� STATE Ce�- ZIP --I S zet 1 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agentof 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 me or my business as identified on this form. <br /> 1 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 F RAL laws. <br /> APPLICANT'S SIGNATURE: DATE: ! �O <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 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 environmentaVsite 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. <br /> TYPE OF SERVICE REQUESTED: T <br /> COMMENTS: / RECEIVE <br /> 'f'A'' �x ' dif�a <br /> MAK 2 b cuud <br /> 5XN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �Z P I E: �1 <br /> Fee Amount: U Amount Paid �q� p Payment Date 3 <br /> Payment Type Invoice# Check# I Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1 111 712 003 <br />