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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property ACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME , <br /> 1 ) <br /> SITE ADDRESS CToC�(�oyl C l� <br /> l �\Street Number Direction Street Name lJ Cit ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) �. r O�W�h <br /> Street Number Y'C�(�o Street Name <br /> owl" � r STATE ZIP <br /> K rby, C A q 12 <br /> Ex. APN# LAND USE APPLICATION# <br /> PHONE#2 Ex. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR < <br /> 1 CHECK if BILLING ADDRESS <br /> BUSINESS NAME nPHONE# EXT. <br /> HOME Or MAILING ADDRESS FAX# <br /> mc-'_ dL • c C/ ( ) <br /> CITYO STATE ZIP �.t <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 forth. <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 FED RAL laws. Q �7 <br /> °SIGNATURE: "DAME �r� D <br /> PROPERTY/BUSINESS OWNER PERATO TANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> lfAppLjcANT 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 and at the same time it is <br /> provided to me or my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: 1:�)O RECEIVED <br /> 20 y <br /> COMMENTS: JUL Z a 'LOLL' <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> 1 HEALTH DEPARTMENT <br /> ACCEPTED BY: nl\/ EMPLOYEE#: DATE: <br /> ,r <br /> ASSIGNED TO: '/Qi EMPLOYEE M DATE: �1 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE; � 02 <br /> Fee Amount: G Amount Paid ` Payment Date '� 2 .211' 22— <br /> Payment Type Invoice# QtieKilill `L/ 35 fl Received By: <br /> EHD 1,�� SR FORM(Golden Rod) <br /> REVISEDSED 1111 11/17/2003 <br />