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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> VEN i M oa- bp-IE Nl4 S <br /> OWNER/OPERATOR <br /> (� CHECK if BILLING ADDRESS <br /> R <br /> FACILITY NAME 11 H •J 't1 1:11 <br /> T MAUAET <br /> SITE ADDRESS <br /> "7� IM� L�-v�ti►'TH 5"j TRAc 530)4 <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 159 Q N EA 1X) L—A-a U-3 Street Number Street Name <br /> CITY STATE ZIP <br /> 2 c CA S3-} <br /> P ONE#1 EXT APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> ( � ` N C CHECK If BILLING ADDRESS <br /> vl <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> 1 S9 o M EAtxv.f LAR-< Lel `T2A 9S3"J-;6 ( ) <br /> CITY1 C STATE ZIP r�'3 <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 to me or my business as identified on this form. <br /> 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. <br /> APPLICANT'S SIGNATURE: RaQm DATE:. <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> ifAPPLICANT is not the BILLING PARTY,proof 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 environmentaftU""assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN"1'as soon as it is available and at&?SS2l 4.is <br /> provided to me or my representative. " C ."v <br /> TYPE OF SERVICE REQUESTED: 4p <br /> COMMENTS: 19 <br /> HFALA4, O C��Ni'Y <br /> DEPS M HT <br /> ACCEPTED BY: /7 EMPLOYEE#: DATE: <br /> ASSIGNED TO: (1 EMPLOYEE M V DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: dtp/ P i E: <br /> Fee Amount: i5 ou Amount Paid 1S� �� Payment Date / <br /> Payment Type Invoice# Check# D Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> F p 65q 1323 <br />