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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5PdJb a)(-R %"o N- Dtb 0�� Lril�S <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> MO A0 <br /> FACILITY NAME MR . p 1G�>�S <br /> SITE ADDRESS' ,_' ✓dK✓�—�L fl , (JE r--W./ I g SL-QO <br /> 514 Street Number r 7�r, C 71D Code <br /> HOME Or MAILING ADDRESS (H Different from Site Address) WAZERB WpPLIE G)Z CA-f— <br /> ?-4 <br /> A-£24 Stree Number <br /> CITY yy��[t pA�� STATE LP 96f 5 <br /> I <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> (9112 ) 5'D2- OSI <br /> PHONE#2 BOS DISTRICT LOCATON CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> EE <br /> T MOl � <br /> BUSINESS NAMEPHONE# EXT" <br /> R. I 11sSOZ- 05 ► L� <br /> HOMEorMAJUNG.�pp((D� DRESS �, p� J�/�� I ( FAX# <br /> 2-T WA-IF�4009 C {IN'LfE ( ) <br /> CITY G STATE C LPr g-'.3 <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 Rd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: I DATE: I4)ZI t b <br /> PROPERTY/BUSINESS OWNER Fp OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT O <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 same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: D <br /> DF� 14 201 <br /> HE, � �r <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: i EMPLOYEE#: DATE: 12 7 , //o_ <br /> Date Service Completed N already completed): SERVICE CODE: P,E: /zeQ� <br /> Fee Amount: -, aso Amount Pal /7 00 Payment Date �. <br /> Payment Type ✓ Invoice# Check# 7 Q� ecei aa Byd16) <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />