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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 1 OPERATOR <br /> y <br /> CHECK if BILLING ADDRESS 0- <br /> tyw-WOOD Y" 80 <br /> FACILITY NAME o <br /> SITE ADDRESS �- J�C1C_ Cli1 �5 G� r <br /> [' f 1, <br /> Q Sireet NumtZer DlrecEion Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> c ClC? C Street Number Street Name <br /> CITY STATE ZAP <br /> -S?b c 1 <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> cgi,°9) 3 q(5-— �. l 3 <br /> PHONIER Ex-r. BOS DISTRICT LOCATION CODE <br /> c ' } a -a 35; <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR — <br /> IJ f /110 <br /> q� �J j/ CHECK If BILLING ADDRESS <br /> BUSINESS NAME r` ) i 1 J` PHONE# ExT. <br /> u�rrU ( 1 <br /> HOME or MAILING ADDRESS %�'^ FAx# <br /> 162 74 a 171 t0q— h� S c 1 <br /> CITY �{ STATE / C� Zip <br /> cJ �[.k. C. <br /> BILLING ACKNOWLEDGEMENT: 1, 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: � J DATE' I I 1 � Cl Ojo - <br /> PROPERTY!BUSINESS OWNER El OPERATOR/MANAGER ❑ OTHER AIU11ORIzEi)AGENT <br /> ❑ <br /> If.4PPLICAArT is not the BILLINGPARTY,proof of authorization to sign is required Title <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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> CS h V V 3 <br /> W Qu. c <br /> STH DENoNJ <br /> ACCEPTED BY. 11AI EMPLOYEE#: �j/ 1 DATE: <br /> ASSIGNED TO: `� t l EMPLOYEE#: /`J DATE: <br /> 11 1 <br /> Date Service Completed (if already completed): SERVICE CODE: V ,? P i E: R! <br /> Fee Amount: Amount Paid Payment Date 2— <br /> Payment <br /> Payment Type Invoice# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117!2003 <br />