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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> P -t J✓7 J'� <br /> OWNER/OPERATOR <br /> Y ' V- CHECK if BILLING ADDRESS 0 <br /> FACILITY NAME , <br /> SITE ADDRESS �1 rye I' MAn4eC.7 q S3-7(10 <br /> ,22-11 Street Number I DIrection / Street Name CI Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number tree Name <br /> CITY �� ST/�T� ���� <br /> Coo <br /> PHONE#1 E-* APN# LAN(c`'D USE APPLICATION# <br /> (It" &2q-q2-1 <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> K C G O CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> 2-/G— <br /> HOME or MAILING ADDRESS FAX# <br /> CITY C STATE 0 Q ZIP '1 537 <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,STAT d FEDER laws. <br /> APPLICANT'S SIGNATURE: DATE:_ 1 / /05/2,vl <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLIC 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: oc �a�Sv�t <br /> COMMENTS: A® <br /> IVpIV V132019 <br /> S EN OAQUIN <br /> Nil H cot <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> 14 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: 2 Amount Paid JZ _ Payment Date 1 ( 13 I I q <br /> Payment Type V S Invoice# Check# Received By: <br /> EHD 48-02-025 3� Z SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />