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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> rrrrr�,,Li A � � VV <br /> OWNER/OPERATOR <br /> - _ CHECK If BILLING ADDRESS <br /> / G <br /> FACILITY NAME <br /> 1-1 V 5C J2 e '5 / � / ��7 7 t rx / <br /> SITE ADDRESS 9f �S 1. l/ (N�L✓�/u ��C Ul/� FF <br /> �('�Z/��T�N <br /> Street Nurnber Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) X2/ <br /> Street Number Street Name / <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (s-la ) -9s� oo -140 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> C, CHECK If BILLING ADDRESS <br /> BUSINESS NAME L PHONE# EXT. <br /> 'rl 5 - G o )4-1 - sat <br /> HOME or MAILIN DDRESS FAX <br /> CITY ,)L $TATEC^ 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 a cation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards T STE and LSD RAL laws. <br /> APPLICANT'S SIGNATURE: jaw DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERAT /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 and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: DWT5 1ZE Vi E `— <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: G EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P1 E: 0 <br /> Fee Amount: q�b Amount Paid Payment Date g 2— Z� <br /> Payment Type Invoice# Check# 3 1 Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />