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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> .& <br /> �.Dw� S v _ ,3 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS Y l <br /> LAu, Street Number Direction N treat N.m. city Ynclf) ZI Code�S <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 41 Street Number Stre.tName IV M�n 5t <br /> CITY STATE ZIP <br /> Vvl�thk2Ca 'A C1 < <br /> PHrnfONEn#1 E:*. APN# LAND USE APPLICATION# <br /> PHONE#2ExT BOS DISTRICT LOCATION CODE <br /> �6 b <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Em <br /> HOME Or MAILING ADDRESS FAX# <br /> 2 ( ) <br /> CITY C STATE ZIP CIS <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 /> 1 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: DATE: 2 I I t <br /> PROPERTY/BUSINESS OWNER® OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> /.fAPPL/CANT 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 environmental/site assessment <br /> Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available a same time it Is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: VED <br /> COMMENTS: rl'fj 2010 <br /> SAN JOAQUINCOUNTY <br /> H ENVIRONMENTgL <br /> FAUN DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: 00 t EMPLOYEE#: TO DATE: (' ry nl1 <br /> Date Service Completed (if already completed): SERVICE CODE: 5 P 1 E: IAW <br /> 'V <br /> Fee Amount: 5 W " `v Amount Paid Payment Date '2 ' abao <br /> r <br /> Payment Type Invoice# Check# Received By: <br /> EHD 46-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />