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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST _ <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> ,U^ �O�L� � CHECK If BILLING ADDRESS <br /> 'Y <br /> Ni 1 <br /> �( FACILITY NAME 11/1 <br /> Y" SITE ADDRESS a')-5- 5 (,heiro KAY' L <br /> Street Number I Direction Street Name city T—Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#I EM APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 Ea . BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS D <br /> BUSINESS NAME PHONE# Z Y�0 7. <br /> �( r E , M'r(S 6J Z <br /> HOME Or MAILING ADDRESS FAX# <br /> [A L-Aw KID ( ) <br /> CITY ���LL11 o.t� STATE ZIP i 30 <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 or <br /> 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,StandardZSTAand FEDERAL aws. <br /> APPLICANT'S SIGNATURE: Nyc W yl f DATE: (tern--2 3 CO Z T <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANTis not the BILLING PARTY proofofauthoriZation to Sign is required` Title <br /> 1 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 enviromnental/site assessment <br /> information t0 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: UST PAY D <br /> COMMENTS: <br /> JUL232002 <br /> SAN JOAQUIN GOUNTY <br /> ^NIP NLICHEALTN WJICP SISIDN <br /> APPROVED BY: j, o EMPLOYEE#: -"1 'Z Q "L DATE: <br /> ASSIGNED TO: \/1n`� EMPLOYEE#: y1/ O DATE: , '-J'3 . 2 <br /> Date Service Completed (if already completed): SERVICE CODE: 03.e}. P/E: 1*3 � <br /> Fee Amount: oo I Amount Paid Payment Date _ <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-502 <br />