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SAN JOAQUIN UNTY ENVIRONMENTAL HEALTPARTMENT <br /> SERVICE REQUEST <br /> ype of Business or Property FACILITY ID# SERVICE REQUEST# <br /> GT S STA— 40 t,/ ,SCQ ® 2> <br /> OWNER/OPERATOR <br /> Jo'F� ��\J/ CHECK If BILLING ADDRESS El <br /> FACILITY NAME �J /�/ <br /> SITE ADDRESS 7/7 11141 s TO CxLT0 r) 9S Ze 6 <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 3F,17 . FFL/AJ T,-1 o N T JD/L t Vt-- Street Number Street Name <br /> CITY STATE ZIP <br /> 5A-t,) X1.5/ <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> c9—v�► S3 2 qS a <br /> PHONE#2 EXT, BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> ( ) <br /> HOME Or MAILING ADDRESS FAX# <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 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�ATE d FED RAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 0to Lo <br /> PROPERTY/BUSINESS OWNER OPERATO MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICAN 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. <br /> TYPE OF SERVICE REQUESTED: S RECEIVED <br /> COMMENTS: <br /> FEB 10 2004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ' EMPLOYEE#: DATE: /U /� <br /> ASSIGNED TO: EMPLOYEE#: 3 DATE: t a v <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: 1 <br /> Fee Amount: Amount Paid Payment Datet O <br /> Payment Type Invoice# Check# L Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />