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NAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1 Z kk+ c raou <br /> OWNER/OPERATOR <br /> L L- C CHECK If BILLING ADDRESS <br /> Ac �2-Zu <br /> FACILITY NAME r/Z Z^ <br /> SITE ADDRESS �7 th S ��� T V'w Y C /3 9 5 3 7 <br /> Street Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) `` S IC! /0 o <br /> 0-1-0 Street Number Qr7C°�� ��V� Street Name <br /> CITY STATE ZIP <br /> S 0A o;-) S 0 3 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ) <br /> (92 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# T' <br /> 2ZC4 C 2Z /%u A� 33 <br /> HOME or MAILING DDRESS FAX# <br /> a -cam 11ve S l eiov <br /> CITYSTATE L LL ZIP 1 y1 <br /> G! G(NyI()l�l i 1 l <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 or <br /> 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,Standar�STTEd FEDERAL laws. Q� <br /> APPLICANT'S SIGNATURE: DATE: 114110 u <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANAGE OTHER AUTHORIZED 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 same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Fo d D <br /> COMMENTS: <br /> Nov 2 5 zoos <br /> JOAOUIN COUNTY <br /> SAWNv1RONMEN FNT <br /> ACTH 0FPAR <br /> ACCEPTED BY: � C � EMPLOYEE#: DATE: �� 2 t L�i ` 1 � �' yam ( / <br /> ASSIGNED TO: Y( K_ EMPLOYEE#: t-r DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 2 2 o l <br /> Fee Amount: _. ? C, �z; Amount Paid b 6b Payment Date \\1 ZS Q <br /> Payment Type Invoice# Check# l Received By: �T <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />