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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> e \C) <br /> FAciurYNAME �' `003 <br /> SITE ADDRESS �,�3-( 1 >�`r`sL.r' Yt-- � c7c�• �lS 1.�-Q 2 <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> EXT- APN# LAND USE APPLICATION# <br /> PHONE#1 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( 1 _ <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> PHONE# Exr- <br /> BUSINESS NAME l(9 2)-1;)-- 1 9 c5S <br /> HOME or MAILING A RESS FAX# <br /> p . `� ��" lel � 3-n1,�,'t/3 <br /> 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 laws- <br /> APPLICANT'S SIGNATURE: DA'L'E: <br /> ❑ OTHER AUTHORIZED AGENT 14.J �C r <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ,0-- <br /> If <br /> If APPLICANT is not the BILLDVGPARTY,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 andlor environmental/site assessment <br /> information to-the SAN JOAQUIN COUNTY ENvIRONmENi'AL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative- -- ' <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS ' Vl9 <br /> �OO� { <br /> �,AN SV1R NMS CME�� <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: / Z Z DATE: <br /> Date Service Completed (if aiready completed): SERVICE CODE: .. PIE: <br /> Fee Amount: Amount Paid - t Payment Date <br /> �+ <br /> Check# Received By: <br /> Payment Type Invoice# C�. '.- <br /> EHD 48-02-025 <br /> £� <br /> REVISED,11/17120 <br /> SR FORM(Golden) <br /> ;. 4 <br />