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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVIICC/E REQUEST # <br /> a P St-z1. 2i b /� f d O O3 r7 <br /> OWNER / OPERATOR <br /> Pf� l /�o / � �} vn CHECK If BILLING ADDRESS <br /> FACILITY NAMEV <br /> � TA) ILr, J� <br /> SITE ADDRESS . . �)O O �� ('? `" a"I' <br /> Street Number Direction Street Name J J C�ItG Zip Code <br /> HOME or MAILING ADDRESS (If Different from <br /> ]Site�Address) ✓� I� <br /> 1 I 0 Lel � 1 , Street Number Street Name <br /> CITY STATE ZIP <br /> l U, d"IC� Q •_ cls <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> S ? 41 - � g � <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR /fd CHECK if BILLING ADDRESS <br /> US A T PHONE # EXT. <br /> BUSINESS NAME ) /� D <br /> I AV <br /> HOME or MAILING ADDRES / 4 (/ FAx # <br /> CITYyv H §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 w rk toAperformed will be done in accordan e with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STA d F DERAL la . 7 <br /> APPLICANT ' S SIGNATURE : / DATE ; / 2 - <br /> PROPERTY / BUSINESS OWNE> OPERAT R / 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 at the same time it is <br /> provided to me or my representative . Y <br /> TYPE OF SERVICE REQUESTED : S, t �G ZU 72L) <br /> COMMENTS : p O <br /> �CTyOFpq�Nr�4 <br /> MFNT <br /> ACCEPTED BY: S7' /�� \ �� EMPLOYEE # : DATE: l� j <br /> ASSIGNED TO : S`2 LLQ ` � h fold /,a `FCJ a y EMPLOYEE # : DATE: <br /> Date Service Completed ( if already completed) : SERVICE CODE ; �� — (, 5 P / E: w7 ,/ / <br /> Fee Amount : � �j 2 a �' Amount Paid 15oZ �� Payment Date 917:F/ 2/ <br /> Payment Type Invoice # r I J 1 �� � Received By: auttj <br /> EHD 4&02-025 SR FORM (Golden Rod ) <br /> REVISED 11 /17/2003 <br />