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SAN JOAQUIIbUNTY ENVIRONMENTAL HEALTH— PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Properly FACILITY ID# SERVICE REQUEST# <br /> EA I {l(e 11 91 qll ?�2 <br /> OWNER I OPERATOR �L <br /> CHECK NBILLING ADDRESS <br /> FACILITY NAME 0 in . I (1 �,� .. <br /> SITEADDRESS 1 `m cyyk --;A l� l�lXAfUn G Z��O <br /> Str Number Direction Street ams C L Cotla <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Stred Name <br /> CITY STATE ZIP <br /> PHO E#f Ex . APN# LAND USE APPLICATION# <br /> t ) <br /> PHONE#I ExT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 114 <br /> ` 1 on CHECK N BILLING ADDRESS PHONE# En. <br /> ❑ <br /> BUSINESS NAME rl'1\.11A•`.0 <br /> l cx • rQ680 <br /> HOME or MAILING ADDRESS �boyFAX# <br /> G Ii(,, ) 3`1) - a5 D <br /> CITY ,I lW• , -4.. STATE p t\ ZIP 1 <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 /> 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: � I(rDATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT# ILU1 <br /> If APPLICANT is not the BILL/NG PARTY proof of authorization to sign is required rir <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 andeAihe same time it is <br /> provided to me or my representative. %k <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: TtuG <br /> 11 LUUU <br /> SAN JOAOUIN COUNTY <br /> ENVIFONMENTAL <br /> ���}}} H�SLTH DEPARTMENT <br /> C, <br /> ACCEPTED BY: EMPLOYEE M Q� r.T DATE: <br /> ASSIGNED TO: P , i 1 , EMPLOYEE#: !! Q31+ DATE: <br /> Date Service Com ted (n already completed): SERVICE CODE:o I q� PIE: �3 <br /> 03, <br /> Fee Amount: ro i''eq <br /> Amount Paid at S Payment Date I y <br /> Payment Type ✓ Invoice# Check#EHD 4"2-025 <br /> REVISED 11/17/2003 -"-. AU ISRiFO}xr L(Gplden Rod) <br /> ENVIRO17NME44NT H <br /> E <br /> OOALTH <br /> PPPWT/CFR\/If'FC <br />