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SAN JOAQUIJ'' BOUNTY ENVIRONMENTAL HEALTF DEPARTMENT <br /> M - SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ OPERATOR <br /> CHECK If BILLING ADDRESS <br /> t' C <br /> FACILITY NAME <br /> SITE ADDRESS 01 C ,�ur� � n` t,�c�� .S�OCKb�'1 9sICh `J <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Q N (\ � Street Number Street Name <br /> CITY LSTATE CA ZIP��, P�� m 9ob23 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 0) t6i - 1 $ ` C-7 63 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> C l.► 't-e✓ 1 ) �' �rc� � � or ) `-Ib I - 637 <br /> HOME or MAILING ADDRESS FAQ# ) <br /> I'S3 S � , w Q�rY• (J r o H 61 - b 2- <br /> CITY <br /> CITY � � tt �V-N STATE 0 C'\ ZIP Ci S'�-O'�— <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, ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUstNESS OWNER OP RATOR/MANAGER El OTHER AUTHORIZED AGENT <br /> If APPLICANT is n the 1_LING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: NN'hen 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. `(MEN 1 <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: DECj <br /> aw- <br /> SAtd JOAQV�MENPLT`l <br /> H LT"Ole?AATMENT <br /> ACCEPTED BY: t� EMPLOYEE#: LC L'(�W DATE: }1 <br /> ASSIGNED TO: V ` _ i� EMPLOYEE#: r DATE: C <br /> Date Service Completed (if already completed): SERVICE CODE: l } %:, P i E: <br /> Fee Amount: - - ` ` Amount Paid ����e-o Payment Date IID- too <br /> Payment Type �/ Invoice# Check# -]rj 3s` Received By: . <br /> EHD 48-02-025 SR FORM(Goldenr7� <br /> REVISED 11117/2003- 111��� . <br />