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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Busiin` ess or Property ktTru� / FACILITY ID # l �fj SERVICE REQUEST # Sf (? (-) ? C3 fG OWNER/ OPERATOR (�'�` ADDRESS CNECK If BILLING ADDRESS FACILITY NAME PHO E# a EXT. HOME Or MAILING ADDRESS�G ` '0 SITE ADDRESS �; 2v 2 Street Number W Direction n ,A A � j o I Street Name City ( fou) ��j 20� ode HOME Or MAILING ADDRESS (If Different from Site Address) Street Number ZIP ` Street Name ASSIGNED TO: CIN DATE: STATE Zip Date Service Completed (if already completed): PHONE #1 EXT. APN # Fee Amount: Amount Paid LAND USE APPLICATION # PHONE #2 Ext. Invoice # B0S DISTRICT LOCATION CODE CONTRACTOR / SERVICE REOUFSTOR REQUESTOR ) / 1� J .`'� � � /v i i•" CHECK If BILLING CI • ADDRESS BUSINESS NAME i MAY U72W3 PHO E# a EXT. HOME Or MAILING ADDRESS�G ` '0 _ 0FAX# (�Q _,JOAHQ'JIN COUNTY OMENTAL ( fou) 3 If z - o so CITY ice` ^ STATE (M ZIP ` BILLING ACKNOWLEDGEIIYENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this pR lication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, SZ TF- and FEDERAL laws. APPLICANT'S ATURE: DATE: 15T71i Z. PROPERTY / BUSINESS OWNER EI OPERATOR/ MANAGER El OTHER AUTHORIZED AGENT If APPLICANT is not the BILLING PARTY. proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: tog US T COMMENTS: MAY U72W3 SA _,JOAHQ'JIN COUNTY OMENTAL HEALT ACCEPTED BY: EMPLOYEE #: NT DATE: n s" ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: p t E; z U Fee Amount: Amount Paid Payment Date Payment Type Invoice # Check # Received By: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)