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SAN JOAQUIN UOUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> cts S 4-a dt ter, r 8 S � - 99 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> C t r <br /> FACILrrY NAM , k, ' �J <br /> SITE ADDRESS I6gr7D /�_ b`t_o_ - Lf..t-i1 rC/I LI�330 <br /> Street Number Direction Street Name `^,j Ci I Zi Code <br /> HOME or MAILING ADDRESS (if Different from Si(t'e�Addre tl <br /> `-' I Street Number eetN <br /> CITY �hef STATE zip <br /> PHONE#1 E�' APN# LAND USE APPLICATION If <br /> PHONE#2 k;CAL, Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> ELL& <br /> BUSINESS N E PHONE# EXT' <br /> enc 4 4337 <br /> HOME or MAILING ADDRESS FAx# <br /> (0 3 LI . <br /> CITY S \ STATE (2_A zip R 5 c;Z6 Y <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,ppSTATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE\..lLf:.� //t Z�/v DATE: 5-19-69 <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/MANAGER ❑ OTHERAUTHORIZED AGENTIPL& ,11c1 C6,7razrlel "r <br /> IjAPPL1CANT is not the B7LLmc PAR proof of authorization 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 enviro ental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is , at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: M 'Co <br /> SP3't JOPOONN'E"M� <br /> HO� DEW <br /> ACCEPTED BY: OCt UEI .O .A EMPLOYEE#: ®� DATE. T �O Og <br /> ASSIGNED TO: nJ 4.-f p L,( EMPLOYEE#: ' DATE: S �� <br /> Date Service Completed (if already completed): SERVICE CODE: If�e PIE: 2Zpe <br /> Fee Amount: 4 ,f�1 Amount Paid �� Payment Date <br /> RD <br /> Payment Type Invoice# Check# q Received By: <br /> EHD 48-02-025 SR rofW(6olden'Rod) <br /> REVISED 11/17/2003 <br />