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• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> foo qL J <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> S64 M c.i iP_� i� <br /> FACILITY NAME 0&5* lG�vt N iAe 1 YO <br /> SITE ADDRESS 3 3 W <br /> Street Number Direction Street Name * City ✓ Zip Code ��1 <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 /> ( - > / / 7 - oSp —37 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) 2-- 11 919 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �/ CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT' <br /> �G�?C ZGXl <br /> HOME or MAI ING ADDRESS FAX# <br /> 0 32 ( ) <br /> CITY t ` tA STATE <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 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 /> / 1 <br /> APPLICANT'S SIGNATURE: 4--�✓ �. DATE:/ <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Ml-- <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 avai*ft the same time it is <br /> provided to me or my representative. REC'""—NT <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: U Ottr <br /> Sq NUJOAQUIN Cp TYHEALTH RDATMNT <br /> ACCEPTED BY: O L)S t IA ^ EMPLOYEE#: ?� i DATE: <br /> ASSIGNED TO: ��AJ{'u�C EMPLOYEE#: SS DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Cf P 1 E: <br /> Fee Amount: mount PaidP' O S O 6 Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SQ� I(i;oc7drt4Rod)',; <br /> REVISED 11/17/2003 <br />