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V".01 1.d <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property L FACILITY ID# SERVICE REQUEST# <br /> f fl SKDo 330 <br /> OWNER/OPERATOR 1 <br /> �J,,� n/� A lr 1 .Dr i1 CHECK If BILLING ADDRES _ <br /> FACILITY NAME 1 `V u a' 1w lV/ �// � <br /> SREA DRESS `V � a /me I , / �t ^l <br /> Street Number Direction If/t�Je 'I"AlJ/NJ I (�r¢ji C <br /> HOMEDr MAILING ADDRESS (1f Different from Site A dress) /.2- <br /> Street Number Street Name <br /> CITY / r STATE C;4 <br /> ZIP /. <br /> PHONE#1 Ear. APN# LAND USE APPLICATION# <br /> Li5Z <br /> 2 <br /> PH NE#2 T. BOS DISTRICT LOCATION CODE <br /> 1 3mg ll <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR " - <br /> CHECK If BILLING ADDRESS EI <br /> BUSINESS NAME PHONE# ExT. <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 /> 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 Code=tan. STATE and FEDE I. s. (�APPLICANT'SSIGNArr--�IDATE: b/Lair I <br /> PROPERTY/BUSINESS OW ERL.I OPERATO ANAGER ❑ O ORIZED AGENT❑ <br /> IjArruC o1 the BILL/NG 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 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: Yl. RECEIV <br /> COMMENTS: <br /> AUG 2 2 <br /> SAN JOAQUIN OOUNT'f <br /> H&I-TH DEPARTMENT <br /> ACCEPTED B EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (If alf1p,y comp/ ted): SERVICE CODE: P)E: (1 <br /> Fee Amount: l 2'— e.YJ Amount Paid Payment Date <br /> Payment Type V Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />