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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> erg <br /> OWNER/OPERATOR n <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME W <br /> SITE ADDDRESST/ 'Q C,y 111'5369 <br /> �>SC) Street Number Dlrecuon ()a U I ` tree[ a <� Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> 1n U treat Number A r tr15 stmetillm" C <br /> CITYC6 I C $TA= ^JzIP 33-70q <br /> PHONE#1 1 ExT• APN# LAND USE APPLICATION# <br /> (2-.o8) -3-17 - 011 u 2� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> O - <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Aiuss fi— CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT* <br /> 70� 3i UZto� <br /> HOME Or MAILING ADDRESS 1 k 5+(-,f <br /> FAX# <br /> CITY Y'] cT�j - STATE er_0 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. 9 <br /> APPLICANT'S SIGNATURE: ��L� DATE: U' J <br /> PROPERTY/BUS4\ESS OWNER❑ OPERATOR AGER ❑ OTHER AUTHORIZED AGENT 0' 01,1 rci yno- a�r <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 sPA time it is <br /> provided to me or my representative. j M <br /> TYPE OF SERVICE REQUESTED: 1 I`1 V1 ukpc/ �� r <br /> COMMENTS: t I ()(G C a 1Jtitc:� O <br /> .Q, ui v►ve-.� � �a�GQ. f�r'�c�. %J°q ;J ?018 <br /> °t✓ H D�pMENTN <br /> ��ENT <br /> ACCEPTED BY: 1 A V i/l D EMPLOYEE#: DATE: A <br /> ASSIGNED TO: `/ ` 1�ntk EMPLOYEE M DATE: � -q� <br /> Date Service Completed (if already completed): SERVICE CODE: �� P/E: 10c) <br /> Fee Amount: . 00 1 Amount Paid �� b 0--Payment Date <br /> Payment Type Invoice# Check# 3 Rec ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />