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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> l�oa `7U3 7j <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS E] <br /> FACILITY NAME <br /> SITE ADDRESS <br /> street Number Direction /U•�V Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) ^/ , ��� a <br /> Street Number ,Cl Street Name <br /> CITY w�� / e C STATE,/ ZIP <br /> PH.QNE#1 ExT. APN# <br /> LAND USE APPLICATION tf <br /> > <br /> PHONE#2 Ex-r. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> ale— Ap Ewae CHECK if BILLING ADDRESS <br /> BUSINESS NAME PUQNE# Ex,. <br /> HOME Or MAILING ADDRESS AYJ <br /> Lgj O F7- 1 <br /> CITY STATE //f 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 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 FEDE [. IawS. <br /> APPLICANT'S SIGNATURE: DATE: �� l <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT s�/g <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 and at the same time it is <br /> provided to me or my representative. <br /> tN <br /> TYPE OF SERVICE REQUESTED: AW6L."c SC ! g�� ! <br /> COMMENTS: <br /> AUG 222014 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: X Z� <br /> ASSIGNED TO: EMPLOYEE#: DATE: U <br /> Date Service Completed (if already completed): SERVICE CODE: S`2 Z P 1 E: <br /> Fee Amount: (1 Amount Paid 7 Payment Date $` <br /> Payment Type Invoice# Check# / 7S Received By '� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />