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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# S RVICE REQUEST# <br /> OWNER I OPERATOR LLL <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME - <br /> TPcCA 8�--- i✓tor T ,r- q <br /> SITE ADDRESS '1 A,rn,�/� I—AiQ <br /> J O 7 Street Number Dlrectlon i t 11�!'Street Nva tme\ ^.Itv ode <br /> HT AILING ADD 5S (If Different from SitD Address) 47 Q1 ,�V�� rS <br /> Street C ber ` � Street Nam I�� <br /> CITY STATE ZIP <br /> jSI r GA %' 3 . <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (107 ) T 6 - -LI I I . <br /> PHONE#2 E T• SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if SICCING ADDRESS <br /> BUSINESS NAME PHONE# ExT' <br /> HOME or MAILING ADDRESS �� � FAx# ) <br /> t <br /> CITY sf 1 RPN-(:AE STATE CA- <br /> ZIP C9'tgQ <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 FF.DE laws. <br /> APPLICANT'S SIGNATURE: AUTHDATE: ��— Z7 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGE�O �OTHER ORIZED 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 sarrfC me it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: (CLV� <br /> COMMENTS: A� - (/ Sq� C ?D O <br /> v yE9CT��`'OH I N <br /> CO— <br /> ACCEPTED <br /> OACCEPTED BY: EMPLOYEE M DATE: 1 2-7 It O <br /> ASSIGNED TO: Q ��i" EMPLOYEE M DATE: 1 <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 <br /> Fee Amount: ��� Amount Pai q-, dD Payment Date 27 <br /> Payment Type Invoice# Check Receive By: <br /> dW— <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />