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SAN JOAQU.*OUNTY ENVIRONMENTAL HEALTHWARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (�)at> 4&V�A--�GC1 5 0 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS u113\ w. \)-o \e cV-CNr •L.t,*�, . Lc gSIC� <br /> Street Number I I Ion Stroot Name <br /> CI ZI C e <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number stroot Nam <br /> CITY STATE zip <br /> PHONE#1 Err. APN# LAND USE APPLICATION# <br /> PHONE#1 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORF w �j <br /> ` CHECK if BILLING gpDRESSr'� <br /> BUSINESS NAME PHONE# ExT' <br /> HOME or MAILING ADDRESS FAX# <br /> XCQ62n <br /> a.) -IS \ i <br /> CITY 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 <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,Standar ,STATE and FEDERAL la s. J(� <br /> APPLICANT'S SIGNATURE: i DATE:�1 9 /Q t) <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PAR TY.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 atoe��AnN Ott is <br /> provided to me or my representative. AY Ivl / <br /> TYPE OF SERVICE REQUESTED: U15 T r <br /> COMMENTS: AR <br /> SAN JOAOUIN COUN <br /> ENVIRONMENTAL <br /> I-IEALTFI DEPARTME <br /> ACCEPTED BY: EMPLOYEE#: DATE Q <br /> ASSIGNED TO: , C� EMPLOYEE#: '� DATE: <br /> Date Service Completed (if already completed: SERVICE CODE: P/E: 2 30'3 <br /> Fee Amount: ` Amount Paid �,7 1 Payment Date 3 s <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />