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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -7�,f GAs 76 •oo 6 <br /> OWNER/OPERATOR `��1 <br /> fA vu0,C) r—L N t I I I)TE CHECK If BILLING ADDRESS <br /> FACILITY NAME 76 <br /> SITE ADDRESS 5 P�7 r( S o" P&ss R D Cy y s3-76 <br /> � Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (Zo9 ) '.3S - -7 7 77 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (.5io ► 65"-t3 o slo ) 2 `19 - I2- <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �6 V y2 C R-T R/I RN HAP-TI <br /> A n_ I CHECK If BILLING ADDRESS PHONE# EXT. <br /> BUSINESS NAME t` <br /> ( urs LE PE izct:r um S'69-uIcF s �Nc 2G $ S - SS S'6 <br /> HOME or MAILING ADDRESS FAX# <br /> 521 1 RAND NG i ON S— ( ► <br /> CITY LF STATE C /) 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 <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 Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER Ia 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 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: COL-.L> S TA 0-T TLS - 50 <br /> COMMENTS: 1 E(IFUR-M C-0 LP S-M(Z- TLS--3"F O aLIA �Qti <br /> VP- U f6 <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: r <br /> Fee Amount: ^ �'" Amount Paid Paymeni Date 3 Ze <br /> Irg <br /> Payment Type Y Invoice# Check# l Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />