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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> S �� �� <br /> OWNER / OPERATORSic <br /> ( i ) C ` 7 CHECK If BILLING ADDRESS ❑ <br /> FACILITY NAME f J L <br /> SITE ADDRESS C I � t I �% C" C �' 1 hl1 KC1 C) C (L I d I C k <br /> Street lumber Direction Street Name city Zip Code <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 /> ( ) <br /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUES OR <br /> .,, � - CHECK If BILLING ADDRESS <br /> u PHP E # EXT. <br /> BUSINESS NAME 1 � S' y � i (�/ 9 � Y- S I <br /> HOME or MAILING ADDRESS FAX # <br /> 3C) 0l0 � �, , �- Ste- S' Mb ) Verb- L, 3 <br /> CITY STATE ZIP n <br /> � �-121 w. �"� G �� � <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, Standards, STATE andpE aws . ., / <br /> APPLICANT' S SIGNATURE : / DATE : <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER L4� OTHER AUTHORIZED AGENT ❑ <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 available and at the same time it is <br /> provided to me or my representative . �Q <br /> TYPE OF SERVICE REQUESTED : <br /> COMMENTS: , VCs® <br /> JAIv <br /> F do, U/N <br /> rim/ try <br /> ACCEPTED BY : EMPLOYEE #: DATE : NT <br /> ASSIGNED TO : �QWIC I � \� Ct EMPLOYEE # : DATE : 2/ 2 %; 2, <br /> Date Service Completed (if already completed) : SERVICE CODE : 1( PIE : <br /> Fee Amount: � 0 Amount Paid 'T pv Payment Date <br /> Payment Type ` s Invoice # Check # Received By : <br /> EHD 48-02-025 C ' -� L9 515 ` IS SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />