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SAN JOAQUA&UNTY ENVIRONMENTAL HEALTIOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 60 C4 <br /> OWNER/OPERATOR <br /> Q i CHECK if BILLING ADDRESS <br /> FACILITY NAME V1 <br /> V VD v)r <br /> SITE ADDRESS 3`7`� tc) Q <br /> Str et Number Dk street rax -e—'4 Zia Cod* <br /> HOME Or MAILING ADDRESS (if Different from Site Address) IF50 <br /> Street Number M ( Name �(! <br /> CITY� STATE ® n ZIP 53 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> lo��') ov I�lCe <br /> PHONE R ExT• BOS DISTRICT LOCATION CODE <br /> la ) In 5v 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR , CHECK if BILLING ADDRESS D <br /> IJ-06 C,. <br /> BUSINESS NAME PHONE# EXT• <br /> Yo L) o� <br /> HOME or MAILING A DRESS FAX# <br /> c_, <br /> CITY S TE ZIP <br /> L L' <br /> BILLING ACKN WLEDGEMENT: 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: a work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standard7STTE and F 1 s. <br /> APPLICANT'S SIGNATURIi: DATE: a <br /> PROPERTY/BUSINESS OWNER / ANAGER ❑ OTHER AUTHORIZED AGENT 13If APPLICANT is nolOPERATOR/I <br /> 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 thj same time it is <br /> provided to me or my representative. �p <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: �® <br /> N <br /> .g,QTM <br /> ACCEPTED BY: EMPLOYEE#: gejo DATE: It,/7,7 /f <br /> ASSIGNED TO: EMPLOYEE#: �Oc'-XD DATE: 1-),/7,-7// <br /> Date Service Completed (if already completed): SERVICE CODE: o61 PIE. ( LO <br /> Fee Amount: `�Z•OO Amount PaIA71 Payment Date 13 <br /> Payment Type !` Invoice# C # 8 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />