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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> � ro � er Sore �, 23 Sl�ov�s�ti� <br /> OWNER/OPERATOR <br /> 4s 41 CHECK((BILLING ADDRESS <br /> h <br /> FACILITY NAME / u-Q c.. er� P <br /> SITE ADDRESS lT <br /> 5 e. t/V h 5 SNta 7r4(i� 9 zip 3 � <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Strwt NumEer Street Name <br /> CITY STATE zip <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> (Slo ) 316 - 4o�a- <br /> PHONE#2 Err. BIDS DISTRICT LOCATION CODE <br /> I 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /4512m CHECK if BILLING ADDRESS <br /> BUSINESS NAME / roG Q fl f4 e PHONE# E'T- <br /> HOME or MAILING ADDRESS �I S-- w(„fl` S frgr✓ 1 j.37/p (AX# ) <br /> CITY t e4STATE L/. zip '15 �-2 / 1 <br /> BILLING (ACKNOWLEDGEMENT: 1, 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ab(WAN� (�/,ntwut DATE: l d /17 <br /> PROPERTY/BUSINESS OWNERIPd OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> If APPLicAArT is not the BILLING PAR 7Y proof of authorization to sign is required rote <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL 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: N pAyME <br /> COMMENTS: / EO <br /> �V 3 0 2917 <br /> HE1L��'&%?''o <br /> e yr <br /> ACCEPTED BY: Cc,,rS W EMPLOYEE#: 7 DATE: II 25 t� <br /> ASSIGNED TO: �� EMPLOYEE#: DATE: ( \ L <br /> Date Service Completed (if already completed): SERVICE CODE: 0(p ate <br /> P Er <br /> Fee Amount: 1��_ (}� Amount Paid �S�Z Payment D�`ate ` <br /> Payment Type G-G- / Invoice# Ch # C6- Received By: <br /> W\ A.. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br /> C �. 0 t c g A <br />