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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property -'FACILITY 10 #SERVICE REQUEST # <br />~AJrl./S3'/.s-./ <br />OWNER I OPERATOR M CHECK If 81lUNG ADORESSrz(/)/1 VI ~BtA-.'CII/l e» <br />FACIUTYNAME E.R pJ/Ll//~-~//40 <br />SITE ADDRESS '~~/I <br />Di~1 <br />¥I{J('!?9 I ~+tJt::-,e1?'N I 'Is';;;I;;;;~"{ <br />S!teet Number S!teetN.me City liD Code <br />HOME or MAlUNG ADDRESS (If Different from Site Address) <br />Street Number I57---2--("d /#-t/Y /'J S!teet Name <br />CITY STATE ZIp <br />PHONE#1 ~/e?tb---'l7pe exT.I APN'lAND USE APPUCATION'~tI7)()b 3-I;)-tJ-tJ6 f;4-tl5'"-107 <br />PHOHE#2 ExT.BOS DISTRICT ILOCAnON CODE <br />(70"\)L\"1 c,""\~Q~\ <br />CONTRACTOR /SERVICE REQUESTOR <br />REQUESTOR CHECK If B'lUNG ADORESS0 <br />BUSINESS NAME PHONE#EXT. <br />(I <br />HOME or MAluNG ADDRESS FAX # <br />() <br />CITY 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 accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes,SlaM?ERAL~ <br />APPLICANT'SSIGNATURE:~Q.~DATE:\\2.<0 \c-Co <br />PROPERTYI Bust ESSOWNERD OPERATOR I MANAGER 0 OTHER AUTHORIZED AGENT 0 -----------------------If ApPLICANT is not the BILLING PARTY.proof of authorization to sign is required Title <br />AUTHORIZATIO TO RELEASE INFORMATIO :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: <br />COIIIlENTS:I /3 b <br />Re:-lbl7 12e//~ <br />;'11 r·£.~~"7?i. <br />/,Ii ) <br />ASSIGNED TO: <br />ACCEPTED By:EMPLOYEE#: <br />Date SelVice Completed (If already completed): <br />Fee Amount:Amount Paid Payment Date <br />EHD 48-02-025 <br />REVISED 11117/2003 <br />SR FORM (Golden Rod)