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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 0 SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> o� )=t�00 3677 <br /> OWNER/ PERATOR Gh <br /> oMCHECK If BILLING ADDRESS <br /> FACILITY NAME s'I^Q 1 j a <br /> �l�fr ll2Gr <br /> SITE ADDRESS , ; / <br /> Street Number I Direction / Street Name City Zip Code 'N <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (Z' U"-2S— -77-:D),— <br /> PHONE#2 ExT. BO$DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /1 <br /> C� cep CHECK If BILLING ADDRESS " <br /> PHONE# E'R' <br /> BUSINESS NAME :54 ee � Q <br /> HOME Or MAILING ADDRESS FAX# <br /> ,1 00% -I - G oS�n i'fie kv f ( ) <br /> CITY / eL STATE ZIP <br /> A4r 14 <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: j DATE: D xL <br /> PROPERTY/BUSINESS OWNER❑ OPE /MANAGER OTHER AUTHORIZED AGENTto ❑ <br /> If APPLICANT is not the BILLING PARTY proof of au oriZation 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. P <br /> TYPE OF SERVICE REQUESTED: 11)&it) (f 1��I &ryls(/t/t�T- k�'E�V <br /> IVICIVT <br /> COMMENTS: 02 7/1ltytt <br /> H&WRON/No OU <br /> MEgLny DEpAr <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: /✓I r EMPLOYEE# DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date B D <br /> Payment Type Invoice# Check#1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />