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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />OWNER IOPERATOR <br />p I yt AD <br />6MI 1i� <br />CHECK If BILLING ADDRESS <br />FACILITY NAME — <br />�aLoR �� me,� <br />CITY I STATE G <br />SITE ADDRESS �] g-1 <br />Street Number <br />DATE: <br />P 0 J Sltreet NameeV <br />B J <br />Ci I <br />V (Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT.APN <br /># <br />2 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />) <br />Payment Type C Invoice # Check # <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR I (J In l� I ff I�� <br />J `�V 1 V 1 `l 'C.J�J QUI,{ CHECK If BILLING ADDRESS <br />BUSINESS NAME M}/1n <br />PHONE #)-EXT. <br />HOME or MAILING ADDRESS { ��I �� <br />L� <br />FAx#J <br />( ) <br />CITY I STATE G <br />ZIP I 2 <br />DATE: <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 accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standar 1s, STA and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: -7 /1 g <br />PROPERTY / BUSINESS OWNER LY OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />IfAPPLIC41dT isnot the BILLIIVGPARTY. 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 the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: C l" K u T v -R / R <br />2 V V I <br />COMMENTS: <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: f\w�v-ens <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: \ <br />P / E: <br />Fee Amount: <br />Amount Paid <br />2 <br />Payment Date <br />Payment Type C Invoice # Check # <br />Received By: <br />EHD 48-02-025 C�nE' -76 8 St –7SR ZRMGolden Rod) <br />REVISED 11/17/2003 <br />