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e <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> U sT C/Nr-�> f oc' - 5 200 Coa l <br /> OWNER i OPERATOR <br /> / CHECK if BILLING ADDRESS <br /> i 14Sl�. <br /> FACILITY NAME <br /> SITE ADDRESS /SL q rr Km14S �cK I� 9SZa <br /> Street Number I Direction Street Name cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) /ki,� I r�vt �z W�S f ✓c(-� <br /> Street Number Street Name <br /> CITY I`' STATE C ,/I ZIP <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> ( 74) 9 f3 -'s��r <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR >> CHECK If BILLING ADDRESS E] <br /> b if k-<-Sa 1-1 <br /> BUSINESS NAMEn // PHONE# c EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> FSfS � ti4 (iW'( ) 5'Y 9- 6-?s <br /> � �— <br /> CITY 5c�t�� STATE G,n 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 1 have prepared this application and that the w rk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ST E d DE I <br /> APPLICANT'S SIGNATUR ' ^ DATE: <br /> PROPERTY/BUSINESS OWNER OPE TOR/MANAGER 13/ 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: S r <br /> COMMENTS: ^ �_(� T <br /> R4R � <br /> s�j ? y 2011 <br /> '�J"o QUIIV C <br /> On/.fir_ OU/V l' <br /> ACCEPTED BY, �- EMPLOYEE#: DATE: 3 <br /> ASSIGNED TO: EMPLOYEE#: LlZ / DATE: <br /> Date Service Completed (if ady completed): $ERVICE CODE: , P/E: 2 <br /> Fee Amount: Amount Paid 5 L4 Payment Date -s <br /> Payment Type S Invoice# Qbe&k# 0 , S 3 Received By: <br /> EHD 48-02-025 C SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />