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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR L� T CHECK If BILLING ADDRESS <br /> � NS <br /> FALIuiY NAME C FT)fA MU RP'T �Sa t t�� p1 _ <br /> S EAD,DDRESSS �" WEST 0 Tfi <br /> U. <br /> •/' b Street Number Direcon Stnel ame C t Zi Cotle <br /> HOME or I " frnm Site Address) <br /> X Ly 4 -T-D�J Lo„ Street Number Street Name <br /> CITY STATE ZIP JrT <br /> 73-1 <br /> PHONE#1 EXT. ApN# LAND USE APPLICATION# <br /> 93�Sooa <br /> PHONE#2 Ext. I,, WI`s BOS DISTRICT LOCATION CODE <br /> (925) 9 -591 C C2S-'3gQ- S11 <br /> h25 h2 olroo. CONTRACTOR/ SERVICE REQUESTOR <br /> EQUESTOR kim +w 'Apa tq- <br /> CHECK If BILLING ADDRESS <br /> USINESS NAME M 111/1 Ext. <br /> �PA 1 1 V'l �S r- PHONE# _ n ��aar <br /> HOMEO,MAAILINGAD;RE`S, ` �„y 1 ,AX# , <br /> ITY D l//�`77�V`.JJ STATE ZIP 41-! s <br /> 126 -J <br /> BILLING ACKNOW EDGEMENT: 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 JOAQUIN <br /> .? COUNTY Ordinance Codes,Standards,ST and •EDERAL la s. <br /> APPLICANT'S SIGNATURE: 4L4 DATE <br /> PROPERTY/BUSINESS OWNER 13 OPE T'OR/MANAGER ❑ OTHER AUTHORIZED AGENT. , i � <br /> 1fAPPL1CANT is no!the B/LL/NG PARTY proof of authorization to sign is required e <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 /> 'a Information to the SAN JOAQUfN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it Is <br /> provided to me or my representative. �y <br /> ItIll <br /> TYPE OF SERVICE REQUESTED: '00.6 f�L.9>v L"i�F�G�� PAITEp <br /> COMMENTS: 75\ z)- ZQ.' ( MAR S 2411 <br /> S-2-'A <br /> — - <br /> ao �ii <br /> J IIJ <br /> _\L� — �—L SA EN�tH EPAFCl4AEN <br /> ACCEPTED BY: EMPLOYEE#: �O DATE: <br /> ASSIGNED TO: EMPLOYEE#: 120 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: SZ P 1 E: (p 0l <br /> Fee Amount: Amount Paid Payment Date 3 I <br /> Payment Type V" Invoice# Check# 1A Received By: �. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />