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SAN JOAQUIN COUNTY ENVIRONMENTAL IIEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILRY ID 0 SERVICE REQUEST II <br /> YMM I K ?X-4 1 <br /> OWNER 1 OPE R <br /> VCHECK If Bn.uNf3 ADDRESS D <br /> FACRm NAME I-to OA-hM <br /> SITE ADDRESSU II /, <br /> U <br /> 6trN1 Number p"I 1 1 ` r r <br /> FCr�W,2 <br /> HOME or MAILING ADDRESS (If Differentfrom SI a Address) <br /> Sleet NvmpN s srn� <br /> CITY TE ZIP C <br /> PHONE It IL". APN Il LANo USE APPtxAT1oN i ,J <br /> ..S& + LP <br /> PHONE 92 EXT. SOS DISTR;cT 171AT1oN CODE <br /> l 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CUS�a�d�t � _ <br /> CHECK if B14UNO ADDRESS <br /> 6 p <br /> R441 EW :�O r <br /> BuSINEss NAME ` I <br /> HOME or MAILDIG ADDRESS FAX! <br /> If ) <br /> CITY STATE ZIP 111A TDV Ch — na-;!() <br /> BILLING ACIMNN LED MENT: 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 1OAQUIN <br /> COUNTY Ordinance Codes,Standards, TE an EDERAL I �7 <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY 1 Bt:SLNTSS OPERATOR 1?*IA.NAGER ❑ OTHER ALMIORI7ID AGE.YT❑T <br /> 1f APPUGttiT it not the 81LL 'G PARTY proof of authorization to sign is required Ttrlr <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: <br /> COYMENTs: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE IN: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/172003 <br />