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SAN.TOA N COUNTY ENVIRONMENTAL HEAL DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> nss-c C - S T <br /> FACT TY NAME <br /> Ell C NAL L-7ZC zLvM r S o Lil-'-r tv <br /> SITE ADDRESS I �C/ /�/1 _n C� j n � C 20 <br /> St et Number Direction r v G CStreet m L Ck ZiP Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> I ` t Street Number Street Name <br /> CITY <br /> TATE ZIP <br /> � <br /> P ONv#,I !+ v APN# 1 ,a LAND USE APPLICATION# <br /> PHONE#2 EXT• l l/ BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQU TOR ^ - _�`T n. Cjy, CHECK if BILLING ADDRESS <br /> BUSINESS NAME A gM�r�v I IAAA L r 1 ` PHONE# EXT. <br /> HOME Or MAILING ADDRESS <br /> CITY �-� (c STATE 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,StandardsATE and FEDERAL laws. c7 / <br /> APPLICANT'S SIGNATURE, � • � DATE: 2 L 2 C 12-0 14 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is not the BILLING PAR TY 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 apd at the same time it is <br /> provided to me or my representative. J4 <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: C7 <br /> ✓o 25 2� 9 <br /> A <br /> HF t)'OO 9/NTgIJJV <br /> AATMFj►T <br /> ACCEPTED BY: tf Y EMPLOYEE#: DATE: -, zy <br /> ASSIGNED TO: C EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: P/E: I'n <br /> Fee Amount: oc Amount Pai ���•U� Payment Date71 <br /> 2 � 1 lVV! <br /> Payment Type Invoice# Check# �b(o Receiv d By:'- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />