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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 <br /> 'rlY111�O r' <br /> S C� nQ CHECK It BILLING ADDRESS <br /> FACILITY NAME coy (� l <br /> -rac S plus ; aS <br /> SITE ADDRESS f ofS .SOCM M)k gS2-Ll� <br /> Street Number Dlrectlon Street Name city ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) ' <br /> / Street Number r L� Street Name <br /> CITY Go I STATE C ZIP g S Z 4 O <br /> PHONE#? En. APN# LAND USE APPLICATION# <br /> 2z)�i 3 5 Z( s <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQl1ESTQR a S OL O r r D <br /> CHECK if BILLING ADDRESS� <br /> BUSINESS NAME �t J 1 /o 3 Ex' <br /> ` lA t <br /> HOME or MAILING ADDRESSO o FAx# <br /> ( ) <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 a d FE •RAL IawS. 9 <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER D OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is no the BILLING PART P 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 environment t s g��Irleent <br /> Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at k�V1 IS <br /> provided to me or my representative. RECEIVED <br /> TYPE OF SERVICE REQUESTED: Vvmt�l,Q � MAR 18 2MS <br /> COMMENTS: <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: 0A"-/VL <br /> l n!I .n .^� EMPLOYEE M DATE: <br /> ASSIGNED TO: 44>e_ �t `�lVL V EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: I Amount Paid 5 '2� Payment Date l S L <br /> Payment Type Invoice# peck# 127, 33 3/�� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />