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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GDr- D r'- yAuv-�;o3�5 <br /> OWNER/ OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME r _ ^5 <br /> L'IM ^ „'T- <br /> SITE ADDRESS `j� q S MA I d N4A�TEt'_IE <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (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 /> REQUESTORc!_ tcee' CHECK If BILLING ADDRESS <br /> BUSINESS NAME x�! PHO EXT. <br /> LL 5Ef'4C,E 5 ( ) �- 113a <br /> HOME Or MAILING ADDRESS !�A f jAA p�/_r(ec0 (�91 ) _, r,I — 17:3S 1?�C <br /> CITY Fffe,tJo 1/cl�v��+ STATE eA /{ 'tZIP 13-7Z,? <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 icati n anckhat the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stan rds, STA E a d FED L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/N'IANAGER ❑ 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 an tl<ie same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: l kLL DEQ FILL 'Pe(U- '(-a p a <br /> I <br /> COMMENTS: 11?r1pLAC.E � 5 PQR r <br /> 1 u 6 <br /> SPN SOP ONM�TMENj <br /> EN�1R�EpPR <br /> NEPVSN <br /> ACCEPTED BY: C `v�+ EMPLOYEE#: ` 1 ( DATE: 7/L <br /> ASSIGNED TO: N .� EMPLOYEE#: 2� J DATE: "� -e 7 l -7 <br /> Date Service Completed (if already completed): SERVICE CODE: Q P I E: Z C) <br /> Fee Amount: � Amount Paid S (7 1 Payment Date dL:7 D <br /> Payment Type ✓ Invoice# Check# J: Re eived By: <br /> EHD 48-02-025 ' ,SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />