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j SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST . <br /> FOWN <br /> e of Business or Property FACILITY ID# SERVICE REQUEST# <br /> I� �A00222�� S�Oo�5 �75' <br /> ScAS <br /> ER/OPERATOR <br /> CHECK IT BILLING ADDREJ3 <br /> F <br /> FACILITY NAME Aov Q m k <br /> SITE ADDRESS f Q b r ra/V <br /> Street Number Direction t me _/ C Zi Code <br /> HOME or MAILING ADDRESS (If Different from SRO Address) <br /> 909 /U s� +U e r5 s; A 1,t- Al � Street Number S Na <br /> CITY STATE <br /> LC75 6011os CN q5 3.2— <br /> PHONE <br /> .PHONE#4 APN# LAND USE APPLICATION# <br /> t <br /> (4�bftg, q72- 030) <br /> PHONE 92 ExT. BOS DISTRICT LOCATION CODE <br /> f 1 <br /> CONTRACTOR 1 SERVICE REQUEST_ OR <br /> REQUESTOR - CHECK If BILLING ADDRESSO 1 <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( � ) <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 tome or my business as identified on this form. - K. <br /> 1. <br /> 1 also certify that 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDE L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER© OPERATOR/MANAGER OTnER AUTHOR[zEF AGENT❑ <br /> IfAPPLIC,4NT is not the H1LLINGPA-R proo 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. ( �t <br /> �-<TYPE OF SERVICE REQUESTED: C I1 n + Q W n lr 5 �� 'r <br /> COMMENTS: JP <br /> JUN <br /> Q <br /> UIY + 0 2o16 <br /> SAN`C)AQUilli CO(] <br /> H�'A TH O pT AL <br /> ACCEPTED BY: i S J EMPLOYEE#: DATE: 6_ 1;7- 16 <br /> ASSIGNED TO: S EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: d P 1 E: I U2 <br /> Fee Amount: `1�p•� Amount Paid r' i r-- Payment Date R �� <br /> Payment Type M Invoice# Check# UQOU a� Received By: <br /> EHD 45-02-025 Con l k j SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> EEE """`- <br />