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SAN JOAQUOOUNTY ENVIRONMENTAL HEALTHOPPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> CLAS Sf�I1oN . 7s7� s�o� a �� <br /> OWNER/OPERATOR 4 It N UFA M 6-7tcl) S t (,L C. CHECK If BILLING ADDRESS <br /> FACILITY NAME A k C-H /yam L.0 A-A-_t - / <br /> SITE ADDRESSDSSR �� 852-1 ` <br /> yt Strreeet Number Direotian Street Name / Ci JZi Coe <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1TAPN# 7/ LAND USE APPLICATION# <br /> c l �—2(oo—S/ <br /> PHONE#2 EXT' BOS DISTRICT 2 LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR PG L rt-9&0 P�kotCU AA C&'AV ICIESS r IMC <br /> CHECK If BILLING ADDRESS <br /> P6-1 t IK L JCP C--�] <br /> `^ ( F�/r,,Y`•L•Y \ F-�I� H!rOytNAEPnt <br /> E <br /> xT' <br /> BUSINESS NAME a <br /> HOME or MAILING ADDRESS <br /> CITY STATE <br /> ZIP q J 3 O <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 applic on and that the wo be performed will be done in accordance with all SAN]oAQU N <br /> COUNTY Ordinance Codes,Standards,STATE nd FEDEF laws. p <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER% OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 ei `�LQ�A <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 ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the saWe time it is <br /> provided to me or my representative. hh'' �- <br /> nIVE <br /> TYPE OF SERVICE REQUESTED: 1, S ( Q -o V- ( T-pD <br /> COMMENTS: C-OL� � JO �U <br /> ' l fMehl DEP�I'/TgL Ty <br /> DR �Ll — ci t C Lt-IQOAi �ja,� ✓A-L— <br /> J1NE <br /> ACCEPTED BY: EMPLOYEE#: �3 u DATE: I a <br /> 6 L! t/LI � <br /> ASSIGNED TO: /�� F�,-,C � EMPLOYEE#: �3i DATE: Q <br /> Date Service Completed (if already completed): SERVICE CODE: /�d/ PIE: 23v, <br /> Fee Amount: 3/.i v'l� Amount Paid `s Payment Date \) g 0 <br /> Payment Type V/ Invoice# Check# 'Z UA Received By: <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />