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r <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property e FACILITY ID# SERVICE REQUEST# <br /> --7 (P I '::�4-af3-7-7 9'71 <br /> OWNER 1 OPERATOR �Q� 1 al �Ou <br /> �lr�A`Y�1qQn CHECK if BILLING A[]DRES <br /> FACIUTY NAME �2�fp� �C�1 Cr1gv� Q fl �30ti�� 5 M eU1 �rraV,ech asp �e1 , <br /> SITE ADDRESS 2 3 6 W _ �} ]�e Avg, S�vCk�O+n C{�20 2k <br /> St Pt Cit Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> d r 1, 1 o ' Street IJumher Street Name <br /> CITY S-f D STATE ZIP <br /> -1.5�x tai <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (2oq ) 5� 6 � 555 FPHC #Z EXT• BOS DISTRIC LOCATION CODE <br /> oq) 2 � 1311t el)o'.), C> <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> iC� -s CHECK if BILLING ADDRESS <br /> BUSINESS NAME � / PHONE# EXT. <br /> HOME or MAILING ADDRESS PAX# <br /> CITY 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 1 have prepared this application and that the work to be performedw' bene in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards STATE and FEDERAL laws. �` <br /> APPLICANT'S SIGNATURE: x —""4 DATE <br /> PROPERTY I BUSINESS OWNER OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <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 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. P <br /> TYPE OF SERVICE REQUESTED: + , <br /> 17 (f, Co. l�. <br /> COMMENTS: U I JUL <br /> 101 <br /> Cha 1 )T2 01-1;� <DC 130 er5 h I p SAN JOAQUIN 1 COUN <br /> ENVIRONMENTAL <br /> HEALTH DEpARTbRSNT <br /> ACCEPTED BY: /��� EMPLOYEE M DATE: <br /> ASSIGNED TO: V 1,v�5uC4- EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERACE CODE: P I E: <br /> Fee Amount: fs _ 07D I <br /> Amount Paid SZ . Payment Date 12—U-1 l <br /> Payment Type voice# Check# Received By: L/1 > <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />