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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Bu iness or� i ,Property/ FACILITY ID# SERV!PE RE�QUEST# <br /> 04 Q j �l .��I rJdU 232/ Kolltfi�� <br /> OWNER{ PERATO , <br /> �} h� CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME L VA), /W, <br /> I'I( <br /> SITE ADDRESS <br /> Street Number Direction Street Name Ci 2i Code <br /> HOME or MAILING A DRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR r 'I /� <br /> CHECK if BILLING ADDRESS <br /> i <br /> BUSINESS NAM / / PHg{rE# �/ 7 EXT. <br /> HOME or MAILING ADDR SS _ / r tFAAXE## <br /> CITYr /`'1/SSTATE 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 plic tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standard ,STA and FEDERAL law . <br /> APPLICANT'S SIGNATURE: t i/l.C- DATE: v <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AG <br /> IfAPPLiCANT 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 /> TYPE OF SERVICE REQUESTED: //--7 i2t�// f-ti <br /> COMMENTS: T� <br /> 5�p � B X006 <br /> SAN JO R00MEWlkL <br /> i Hv'rN DEPA1iMENt <br /> ACCEPTED BY: ` EMPLOYEE M _ DATE: Iq —29 <br /> ASSIGNED TO: i EMPLOYEE M 0 53 DATE: Tl <br /> Date Service Completed (if already completed: SERVICE CODE: Z <br /> 0 P I E: 3 <br /> Fee Amount: �? e� 7 Amount Paid - Payment Date ff r r r <br /> Payment Type Invoice# Check# Received By k1='' <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />