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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID SERVICE REQUEST# <br /> 60DODS S <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADORESSO <br /> FACILITY NAME <br /> SITE ADDRESS n <br /> 5 `C 7ZaIN m� Direction S[reetName �'PH�cu e I n caaa <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 5933 r q Street Number f Street Nama -1ZI2— <br /> CITY STATE ZIP <br /> C tN (T S 212, <br /> PHONE#1 Exr• APN# LAND USE APPLICATION# <br /> (2 02) 79Li 6'?4 ?- <br /> PHONE#2 Etr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS� <br /> BUSINESS NAME PHONE# Em <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 a d that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE EDERAL jaws. <br /> APPLICANT'S SIGNATURE: 03I34h2/ <br /> DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERAT /MANAGER U/ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT is not the BILLING PAR T➢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: rJSVA, n ME <br /> COMMENTS: �D <br /> M48 3 1202, <br /> JOAQUIN C <br /> HEAD p yjw" Ou r <br /> ACCEPTED BY: 1A 60A C EMPLOYEE#: DATE: 2 JAI y' <br /> ASSIGNED TO: k�A t EMPLOYEE#: DATE: 3✓ 'i <br /> Date Service Competed (if already completed): SERVICE CODE; IIIP I E: Z <br /> Fee Amount: 'tl Amount Paid 5a �' Payment Date 2 <br /> Payment Type Invoice# �5 Received By <br /> h <br /> EHD SR FORM(Golden Rod) <br /> REVISED SED 1111 11/17/2003 <br /> pI�G1t� lI � S `� <br />