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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> M2 ci + "n,, -. Kn0a/0135 <br /> OWNER/OPERATOR <br /> Cr C,y i 0 Ay,ncA 4t <br /> CHECK If BILLING ADDRESS O <br /> FACILITY NAME —t <br /> f: I � 2y , C1 Elr I . <br /> SITE ADDRESS I w S �n C K-t'•.oA <br /> Street Number Direction CL� C I CA Street Name City Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) I J L' 9 (, / Ct VV <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (-ZOL ) 2. y `l 2� 13�3�i10 <br /> PHONE#1 EXT. BOS DISTRICT LOCATION CODE <br /> I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> D a� � /Y v•1 CHECK If BILLING ADDRESS <br /> BUSINESS NAME 1 J i PHONE# EXT. <br /> Z � �--� 'Z O �1 <br /> HOME or MAILING ADDRES tv FAX# <br /> p <br /> CITY <, ).- I °n STATE L ZIP `1 F- Z J 3 <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 /> 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ��` /�� C� 1� DATE: Z& <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT s 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. PAYMENT <br /> TYPE OF SERVICE REQUESTED: Rwf RECEIVE® <br /> COMMENTS: AUG 2 7 2099 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ed on <br /> EMPLOYEE#: DATE: <br /> ASSIGNED TO: li::7- rDC %_LL EMPLOYEE#: DATE: �. -7_ G <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: f <br /> Fee Amount: �� Amount Paid S ? Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />