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SAN JOAQUIN COUNTYENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ OPERATOR <br /> CHECK If BILLING ADDRESS E] <br /> FACILITY NAME <br /> . Mt&fKFc✓ dz l9 C x�+ <br /> SHE ADDRESS if 32,,z3 t t'rYl x.\ <br /> 952 <br /> Street Number Direction Sir et Name Ci �-t"' Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'I EXT• APN# LAND USE APPLICATION# <br /> PH NE Exr. BOS DISTRICT LOCATION CODE <br /> ( ) 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Ii d:n)f00a5 <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# 3Ezr. <br /> HOME Or MAILING A DRESS FAX# �^ <br /> U ( ). <br /> CITY /p STATE 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 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 a cation and that the work to be performed will be done in accordance with all SAN JOAQuiN <br /> COUNTY Ordinance Codes,Standards, T;and FEDERAL laws. //AA '' <br /> APPLICANT'S SIGNATURE: 'W� DATE: Iq - <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENviRONME:NTAL 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: S )Q _t'�� Y!4EN <br /> COMMENTS: FtE <br /> MAY 2 � 200 <br /> SN'ENV RONM <br /> H�THDEPAR O, <br /> ACCEPTED BY: a C-1 UF C EMPLOYEE#: 3 DATE: S 26 0 p <br /> ASSIGNED TO: /J s d. A t7-- EMPLOYEEM / Lf Z'2— DATE: S^ 2p Osd <br /> Date Service Completed'(if already Completed): SERVICE CODE: t4 e' P I E: 3 0 dy <br /> Fee Amount: �9 C , D� Amount Paid a IL 00 Payment Date 70 Q g <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 ;SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />