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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property O'ACILITy Iq# SERVICE REQUEST# <br /> illl�U,SU S ogy q <br /> OWNER/OPERATOR <br /> / CHECK If BILLING ADDRESS 13 <br /> FACILITY NAME <br /> � O <br /> SITE DDRESS_ 'J <br /> Street Number "tom 9f `U� <br /> Diredlon eel NRnfe ✓ �t ZI Cotle <br /> FIRM Or MAILING ADDR (If Differ. /(d <br /> nt from Site dress) <br /> � <br /> " Street Number Slreel Name <br /> CRY // STATE Zip <br /> �7 <br /> PHONE#f Ex, APN# LAND USE APPLICATION# <br /> ( ) ( �—I�Lq <br /> PHONE#2 En. BOS DISTRICT <br /> ( ) LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> h CHECK if <br /> PH NE# BILLING ADDRESS <br /> BUSINESS NAME E • <br /> NOME or MAILING ADDRESS FAX# ( I <br /> zr <br /> CITY STATECA 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 /> El" <br /> lso 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 andFEDERALlaws. G <br /> PPLICANT'SSIGNATURE: �j�/G /C. ' may �j�a DATE: <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER 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 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 /> Rod TYPE OF SERVICE REQUESTED: f/�)Sol On M <br /> COMMENTS: 40 �V <br /> G <br /> R <br /> 41140" <br /> ? <br /> g ?o <br /> QUivc <br /> N�cyl�npN NCDU <br /> yOF '1fFi yT�N <br /> T <br /> ACCEPTED BY: EMPLOYEE#: AM DATE: I `fjl <br /> ASSIGNED TO: ' V1 I - EMPLOYEE#: qgqq DATE: l� <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: 03 <br /> Fee Amount: Amount Pal 15 bD Payment Date 9121 <br /> Payment Type Invoice# Check# 3O.2—q Received By: - <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> S <br />