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SAN JOAQUI•N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADORESSM, <br /> FACILITY NAME ! lr p <br /> SITE ADDRESS 2 1 SO I EwSA 1-2-0 <br /> Street Number Dlret_tinn I treet Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) &;t-(Z c�11 V d <br /> Street Number treat N—e <br /> CITY STATE ZIP <br /> PHONE#1 ExT APN# LAND USE APPLICATION# <br /> (2<V1 ) X72 - 3Z?(o -1 of(0 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS 1-3 <br /> BUSINESS NAME PHONE# EXT. <br /> (94CO CX <br /> HOME or MAILING ADDRES (� FAx# r� <br /> (-14`1) <br /> CITY ,(V\ STATE (—A <br /> ZIP ��1(a U <br /> BILLING ACKNOWLEDGEMENT: 1, 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: , DATE: c.rc In y� _Z to 17 <br /> PROPERTY/BUSINESSOWNER❑ OPF.r�— R/MANAGER ❑ OTHER AUTHORIZED AGENTO Ctr 1r, l j c,T_ <br /> (APPLICANr is not the Bil.l.ty(;PjRI r,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: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />