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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Bu ' ess or Prope FACILITY ID# SERVICE REQUEST# <br /> 1-V <br /> OWNER PERATOR / <br /> CHECK if BILLING ADDRESS E] <br /> FACILITY NAME /,,�� 7 t <br /> SITE ADDRESS0 <br /> e' . as 9 <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME Or MAILING ADDRESS (If/Different from Site Address) <br /> w� Street Number (/U(,V� Street N wl� <br /> CITYLZmSTATE ZIP i'�o <br /> ik±t)- <br /> /� ExT. APN# LAND USE APPLICATION# <br /> Xf <br /> U) �obO 2 — �2 fi—/(�PHONEE#2 `J / ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PH, E� EXT, <br /> HOME Or MAILING DRESS /' � FAX# <br /> CITY J1 ( /15 —STATE 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 appli tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST T and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: l DATE: <br /> PROPERTY <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ E <br /> OTHER AUTHORIZED AGENT- <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. n p YMEN-1 <br /> TYPE OF SERVICE REQUESTED: Ct ST F( 7— RSC J <br /> COMMENTS: MAR 19 200 <br /> SAN JOAQUIN COUNT't <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: i EMPLOYEE M 3�,/ DATE: <br /> ASSIGNED TO: EMPLOYEE M l DATE: <br /> yL , � (57 G <br /> Date Service Completed (if already completed): SERVICE CODE: d`i P!E:-?-3_ C,'? <br /> Fee Amount: 5 �� Amount Paid g c_ Payment Date '31\11 09 <br /> Payment Type Invoice# Check# Z Received By: �- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />