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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> fA DOI $O - SQ00�Gwl <br /> OWNER/OPERATOR , <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAMECr�40\tA l— I S <br /> SITE ADDRESS �nAql✓.L S l� q\Ani S �S C4 lc r( 9S S 29 <br /> V <br /> -ASbeet Number Direction Street Name ci ZI Cotle <br /> HOME orMAILING ADDRESS (ifDifferent from Site Address) <br /> se 0 V S `l\ r�`1 V ` Street Number Stree!Name <br /> CITY 1 �pv STE zip <br /> PHONE#1 D ] APN# LAND USE APPLICATION <br /> PHONE#2 /J EST. BOS DISTRICT LOCATION CODE <br /> UX CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> zqkv"� n �L CNECK If BILLING ADDRESS <br /> BUSINESS NAME P— P Nv Exp <br /> HOME or M LING ADDRJ SS FA%# Ul 0 1 V <br /> a� ,-j ave ( , <br /> CITY I CA v P Q 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 accor ante with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. (j 77 <br /> APPLICANT'S SIGNATURE: v� DATE: �` v <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> IfAPPLfCANT 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 environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at w1ric tinte it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: 1podcowgmj,1'd� flI <br /> COMMENTS: <br /> y��aEPMFNTA�Iy <br /> ��FNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 22 <br /> ASSIGNED TO: 1' EMPLOYEE#: DATE: <br /> Date Service Co pie ready completed): SERVICE CODE: Oto PIE: 1W2 <br /> 2 <br /> Fee Amou : t�2 Amount Paid I"J Payment Date 2--TZZ <br /> Payment Ty Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> P ,o52 c�30 S <br />