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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 63570 <br /> OWNERI'OPE TOR <br /> CHECK If BILLING AODRE55 <br /> FACILITY NAME ll <br /> U� <br /> SITEADDRESS 17i'{ I . ..•, "„ r�,,,� /,t,,,` 1 - Cl�—tr�(�, <br /> Street Number Direellon W'^1 �V`Street Namtre V tV'�J Cll �T/ _`ZI CodeU <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Slme[Number V� Street Name <br /> CITY r,„ O STATE ZIPS <br /> PHONE#1/y\ �y ExT• APN# LAND USE APPLICATION# <br /> (Wc ) \� — `—(R <br /> PHONE#2 Ex. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR O <br /> r1 C� AA1 <br /> V � l CHECK If BILLING ADDRESS <br /> h <br /> BUSINESS NAME PHONE# EXT. <br /> � 5 — `'tC�Z� <br /> HOME or MAILING ADDRESS IFAx# <br /> qn a tm kilc I ( ) <br /> CITY A/Y�- `_ STATE (`1/Y 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:)Q DATE; <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICA 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: RQd 09 <br /> ME <br /> COMMENTS: �VCD <br /> y�TV1, 'At COIJIV <br /> �E <br /> ACCEPTED BY: EMPLOYEE M DATE: MIr <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: 1W; <br /> Fee Amount: (';Z o_ Amount Paid Payment Date y�t <br /> Ot 2 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />