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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> o o <br /> OWNER/OPERATOR <br /> T /,V� CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRE <br /> StreetNumber I pirecllon f rWl L <br /> HOME or MAILING ADDRESS 1(if DD.i�ff'eren{�t from}SI�te AddresTs) <br /> 1 lJ'" U� ` ' Z V Slreet Number Slreel Name <br /> CITY l STATE ZIP <br /> �*�CaUtt lx cia 9fLIF <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (X-?) �y 7 <br /> PHONE#2 Ex. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Eo. <br /> HOME Or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY STATE LP <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[his application d that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S an EDERAt.laws. <br /> \/APPLICANT'S SIGNATURE: DATE: Z 6 <br /> PROPERTY/BUSINESS OWNER OPERATOR ANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT 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 environmenjal/site assessment <br /> Information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at Aa e time It Is <br /> provided to me or my representative. ^I M1' <br /> TYPE OF SERVICE REQUESTED: L Q�� -� /V <br /> COMMENTS: <br /> 1 <br /> �N cr400 MEN gIJ <br /> A�rMFN7' <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: �,� a EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: P1 E: <br /> Fee Amount: 5 2 — Amount Paiop /Vr Payment Date (° 2 <br /> Payment Type Invoice# Check# J 2ja�3 9 Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> REVISED 11/17/2003 <br /> P 52--7ULI1 <br />