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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 /> 1 � CHECK If BILLING ADDRESS L,.n <br /> FACILITY NAME Cly, J fit!' " 6o, 3 <br /> SITE ADDRESS QrU rr '►�1]mber F�tlan I�� � Street Name <br /> C t ZI Code <br /> HOME Or MAIL(=, -TING ADDRESS (If Different from Site Address) <br /> y ��l O t`- Street Number Street Name <br /> CITY STATE ZIP <br /> 2G <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> Q-T 61 7tG <br /> PHONE 92 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SER ERE UESTO <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME , PHONE# EXT. <br /> 7 CL.0 1 �� '� ,4 G3 ILA <br /> HOME or MAILING ADDRESS FAX# <br /> CITYS�C]1~4��dy�) STATE ZIP <br /> a6 <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 farm. <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 PED RAL laws. I <br /> APPLICANT'S SIGNATURE: vc DATE: l� <br /> PROPERTY/BUSINESS OWNER❑ OPERAT /MANAGER ❑ THER AUTHORIZED AGENT❑ <br /> If APPLICANT 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 environment MEN"t <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and atiauveir�� <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: MiltExi jUN 16 202 <br /> COMMENTS: <br /> SAN JOAQUIN COU"Ty <br /> E.NVIRONMENTA <br /> HEALTH DEPARTM NT <br /> ACCEPTED BY: t /� , EMPLOYEE M DATE: l('f /I ' <br /> ASSIGNED TO: v [� Q _ EMPLOYEE#: DATE: J Q ZI <br /> Date Service Completed (if already)completed): SERVICE CODE; O P/E: til] <br /> Fee Amount'Q I Amount Paid 1 S 2 Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> Q t05q(0q9 b <br />