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SAN JOAQUII*UNTY ENVIRONMENTAL HEALTH*ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> srrtot� ov 51 <br /> OWNER 1 QPEPATs7 <br /> '— �„� 5 CHECK if BILLING ADORESSi,J+r7, <br /> FACILITY NAME �(,D_ <br /> SITE ADDRESS <br /> Streel Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#1 EXT. APN tt LAND USE APPLICATION# <br /> PHONE#2 EXT, SOS DISTRICT LQCI CODE <br /> ( 1 <br /> CONTRACTOR J SERVICE REQUESTOR <br /> REQUESTOR <br /> +y� CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# ExT. <br /> 5�V-V i ce- (46q "D I-e -Cafe$ <br /> HOME or MAILING ADDRS FAx# <br /> -1b a"L-L&o Avee (qo a13-60 '* <br /> CITY se' STATE CA 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 /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUrN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: . � DATE:' <br /> �t;tt,, i. {�; .. <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT II <br /> 1fAPPLlcANT is not the BILLING PARTY proof ofauthorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1,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 environmentaVsite assessment <br /> information to the SAN JOAQTJTN 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: tr n " <br /> COMMENTS: ��� VA Dv Vte5SUVft- se,.1 W&r W6_S VqcCal e(A' Cda"�p tek al(90 <br /> ACCEPTED BY: EMPLOYEE#: TE: <br /> ASSIGNED TO: EMPLOYEE 71 <br /> 1ATE: <br /> Date Service Completed (if already completed): SERVI CODE: PIE: <br /> Fee Amount: r Amount Paid Y i (? Payme Date \12 0 q <br /> Payment Type Invoice# Check# Received By:I N'4 „ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />