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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER 1 OPERATOR n <br /> ,',,' CHECK if BILLING ADDRESS <br /> �J�f <br /> FACILITY NAME ` . I (— <br /> SITE ADDRESS�> V� 4- a y —Frig C,It g 5 3 6`� <br /> SC) Street Number Direction �a U I ` StreetP a �� 1 Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> 10 U treat Number `r�7 street C <br /> CITY STATE 71P 3 7c <br /> C6 NSF 'J <br /> PHONE#1 Exi• APN# LAND USE APPLICATION# <br /> —3--1 7 - On <br /> 1-2 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> �tos� O ` - <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR,--Vie Ajus <br /> � CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# En, <br /> $ l�SSpcta`�CS z�i zdb 3i`i - UZ�o� <br /> HOME or MAILING ADDRESS I i FAX# <br /> CITY 10 <br /> 6T S p - STATE _-o ZIP Q 3-70-->- <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.APPLICANT'S SIGNATURE: 1 DATE: O q <br /> 7 1 ( �` <br /> PROPERTY/BUSLNESS OWNER❑ OPERATOR?MANAGER ❑ OTHER AUTHORIZED AGENT 0' Pt-,(rci h10.na�&e- <br /> IfAPPLICANT is not the BiLLINGPARTY,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 sPA time it is <br /> provided to me or my representative. j M <br /> TYPE OF SERVICE REQUESTED: P <br /> COMMENTS: l0. V V I 1 ( -- (-4-()(Cl La 1Jytc: 6 � �,�S�1nS %JOrt v <br /> A� HRONM�OVN <br /> DEp ENTq( <br /> ��ENT <br /> ACCEPTED BY: 1 V l V P ill EMPLOYEE#: DATE: A <br /> ASSIGNED TO: l/ , CA <br /> A�ntk EMPLOYEE M DATE: � -q-F <br /> Date Service Commple`t-e1d (if already completed): SERVICE CODE: �� P/E: 100 <br /> Fee Amount: �� Amount Paid q��, b b Payment Date C5V <br /> Payment Type Invoice# Check# 3 Rec ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />