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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNEKOP,ERATO <br /> V �� ( CHECK If BILLING ADDRESS ' <br /> FACILILYNAME <br /> ctionAD_DlRAESS <br /> 6 S �(/ {/�� ZG, <br /> 9 Z �J treet Nu DireC GVo gtreet Name I <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY - STA ZIP <br /> 4 S`z Z U <br /> PHONE#1EXT• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR n -- — CHECK if BILLING ADDRESS <br /> BUSINESS NAM 2z C PH # / �,' -� EXT. <br /> Ccrvt � v r�- <br /> 7-7 - <br /> HOM-...M ,..ennRFSS / ' -� _ RAY t! . O -> I <br /> 5-3 2- j44CIle <br /> CITY t/ STATE,/ ZIP <br /> BILLING ACKNO LEDGEMENT: i, the undersin d property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIR NMENTAL 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 formed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE n �EDRAL la <br /> APPLICANT'S SIGNATURE:}C DATE: <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/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 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: OIL <br /> �I <br /> COMMENTS: I� y/ y/qi� ��E���► 0220 <br /> VlN co NN <br /> SA EN0 RONMEt-T ENT <br /> STH DEPAR <br /> ACCEPTED BY: EMPLOYEE#: R p DATE: <br /> ASSIGNED TO: S EMPLOYEE#: 0�1 L DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: �Z P I E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type ul: Invoice# Check# ,-_4_ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />