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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST Pn 05q7 N5 <br /> Type of Business or PropertySa�2 FACILITY ID# SERVICE REQUEST# <br /> U PDD 2/V 7N7 q(q�- <br /> OWNERI OPERATOR <br /> l / CHECK If BILLING ADORESS <br /> FACILITY NAME <br /> ac.v <br /> SITEADDRESS O�/`7 J�JU`p`rG✓ .� �y � y ) ���J <br /> (� Street Number Direction [•/ Street Name CI Zip Code <br /> HOME Or MAIL140 ADDRESS (If Different from Site Address) (\� --A- <br /> 1 Street Numberv— <br /> CITYC fv 1 STATE ZIP <br /> PHONE#1 J J 1 EM APN# LAND USE APPLICATION# !/v <br /> ( 07 X32 <br /> PHONE#2 Ex . BIDS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE 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 /> 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE:'/ DATE: <br /> PROPERTY/BUSINESS OWNER❑ 16PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> 1fAPPLtoANTisnotthe B/LLINGPARTY 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/sitar�apC ment T <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the S3pTe Mlia <br /> provided to me or my representative. ECie D <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: LI- C ^ D O <br /> J[ 1 JOAQUIN CO <br /> Hit D NMENTTY <br /> EPARTA NT <br /> ACCEPTED BY: EMPLOYEE M . DATE: <br /> ASSIGNED TO: 0-" <br /> _ EMPLOYEE M DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: f PIE: 1016i <br /> 'v <br /> Fee Amount: Amount Paid /Sa�G Payment Date `SI' <br /> Payment Type Invoice# Check# 3b .2—'7Lf 01 Received By: <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />