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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> �v . 4::! /x / IMOD ? S R00 % a4 (0 <br /> OWNER / OPERATOR <br /> ✓C „ � t.� ol IKIod E 4 �)�T <br /> FACILITY NAME 13 <br /> S CHECK If BILLING ADDRESS <br /> v! /;� <br /> e�rJc,�L U �=�2 O �� Sir � v <br /> SITE ADDRESS , / � / / `* /J� <br /> Street Number Direction Street Name it l ZJi Code (l� <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 /> PHONE #2 EXT, BOS DISTRICT LOCATION CODE <br /> ( sib ) � •- �/ � v <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR _ _ _ <br /> T`�� k) r-O _ ` x �vx _ / � /� r`` / . 11� CHECK If BILLING ADDRESS <br /> BUSIN SS NAME /V K�/ /l/ �(/ , I L (J � V/ ✓'V PHONE # EXT. <br /> 13,11 <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 <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 and FEDERAL laws . / <br /> APPLICANT' S SIGNATURE # � _�--� DATE : ! <br /> PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT gcelt ; fy -elwool <br /> a <br /> IfAPPLICANT is not the BILLING PARTY proof of authorization to sign is required /, £S lJ/ T it e4�d D� <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable, 1 , 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. p �s <br /> TYPE OF SERVICE REQUESTED : �L� 7 - C <br /> COMMENTS: GQW0�� waft 4J <br /> s,� oC ` 8 ?D19 <br /> Etyl,0, QUiN <br /> tiryo� NTAc <br /> e <br /> ACCEPTED BY: EMPLOYEE # : DATE : / <br /> ASSIGNED TO : EMPLOYEE M C/ DATE : <br /> �� <br /> Date Service Completed ( if already completed) : �— SERVICE CODE : / k P / E : 2��6 <br /> Fee Amount: z j G' Amount Paid Payment Date ( 0 I <br /> Payment Type L Invoice # Check # Z4 <br /> 33 Received By : <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />