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DAN JOAQUIN UOUNTYENVIRONMENTALHEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> • Type of Business or Property 17 FACILITY ID# SERVICE REQUEST# <br /> JZ`f )' S2do5 _ <br /> OWNER/ OPERATOR /' 1 - <br /> nl�e l „^[,ydµ 0^ `, e, ,) CHECK If BILLING ADDRESS <br /> FACILITY NAME Fr ` V�M`.l!' 1�J�/,� - `- �1_,�' <br /> SITE ADDRESS t v sm C Llan I r.& e �" ^C_1 C.CL'A f <br /> Street Number Direction Street are rYe, !'� city ZIP Code <br /> HOME Qr MAILINGADDRESS (If Different from Site Address) <br /> 1 •�/• �6 S` Street Number Street Name <br /> CITYSTATE ZIP <br /> )V3 SZ-OI <br /> PHONE#t APN# LAND USE APPLICATION# <br /> (7-011) 239 <br /> PHONE#2 Ex . BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME r 1' PHONE# 1 U ' <br /> re—r, Cohs�• Corkcn Z 23 l —35Z,\ <br /> HOME or MAILING ADDRESS FAX# <br /> 0 0 <br /> lyl (ZOR) qb3 - IL <br /> CITY C Sl C) 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 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,Standards,STATE and FEDERAulaws. n <br /> APPLICANT'S SIGNATURE: i/`— DATE: 2— <br /> PROPERTY/ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IjAPPLIcfNT is not the B7LL,rNG PARTY proof of authorization to sign is required Titre <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 t o time it is <br /> provided to me or my representative. y <br /> TYPE OF SERVICE REQUESTED: tAl I C 041�u\--TPf I 0 <br /> COMMENTS: .� <br /> ul�lRe� �e,}�er- � SSC- r� s9N/NZ��oa <br /> ACCEPTED BY: 1JG EMPLOYEE#: 01 S 3 DATE• 2' Z`tJd� <br /> ASSIGNEDTO: r, /m(�-t EMPLOYEE#: Z� Q DATE: Z-f2 .0p <br /> Date Service Completed (if already completed): SERVICE CODE: � PIE: <br /> Fee Amount: OI iZ / Amount Paid - Payment Date <br /> Payment Type Invoice# Check# Received By: _ <br /> EHD 48-02-025 '.:,6R F�OR[vli(�olden Rod) ' <br /> REVISED 11/17/2003 <br />