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SAN JOAQ .a'COUNTY ENVIRONMENTAL HEALT EPARTMFNT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> a S <br /> OWNERIOPERATOR <br /> CHECK if BILLING ADDRESS El <br /> FACILITY NAME <br /> SITEADDRES$ 9533�- <br /> Street Number Direction Street Name C,ty Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> . Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t 77# LAND USE APPLICATION# <br /> I I <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR lie— rLeMmmm <br /> CHECK If BILLING ADDRESS 2T <br /> BUSINESS NAME PHONE# EXT, <br /> c I -5 <br /> HOME Or MAILING ADDRESS FAX# r� e <br /> O N. e ( O ) — ?JS D <br /> CITY STATE ZIP p�] <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge tlrat 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 fomt. <br /> 1 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �L— .S G `/ DATE: MQ sd <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT, il:YtrC <br /> APPLICANT is not the/hLLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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. ENT <br /> TYPE OF SERVICE REQUESTED: -E\V <br /> COMMENTS: <br /> Mph <br /> DU <br /> ¢UM COUWTI <br /> iFMENt <br /> ne?Ap F1tT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMP LOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICECODE: /� p I E: T y <br /> Fee Amount: Amount Paid lf�� 0D Payment/Date[ <br /> Y <br /> Payment Type L/ Invoice# Check# ,�534. RecelvedBy: 7� <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 + '�`.P � . IT r11 SR FORM(Golden Rod) <br /> I{ I t f� tl�r➢+fll JAIL <br />