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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> r-e 5c, C5 CHECK If BILLING ADDRESS <br /> FACILITY NAME lJ <br /> SITEADDRESS –753, C ✓1 AVP ttOc� C/So� <br /> N <br /> Street umber Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CIN STATE ZIP <br /> PHONE#'1 EXT• APN#A ` LAND USE APPLICATION# <br /> ( ) 1- V / <br /> PHONE#2 EXT. B0S DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEST O <br /> CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME (' 11 PHONE# Exr. <br /> C 7Q 7--3S-1C(9 <br /> J-- <br /> HOME or MAILING ADDRESS FAX# <br /> I I o f -7 S (0ccr) <br /> CITYst nqoJP /� STATE C6 ZIP 4535 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, ope'ra'tor 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#iri applica'on and li he work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stan a�dTATEn( FE 'RA ,laws. <br /> APPLICANT'S SIGNATURE: - Dxr> <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT f® �Gc? 1rr c,6/- <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 /> abc,ve 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: U <br /> COMMENTS: <br /> 116&- <br /> Qelveo <br /> SAY 08 Z019 <br /> S�JO <br /> I IN COYN7y <br /> ACCEPTED BY: EMPLOYEE DATE: SPAR IAL <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE:49,02, <br /> Fee Amount: Amount Paid !'S� « , Payment Date 5�g r 1 <br /> Payment Type S , Invoice# Check `qa7/y] Received By: <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />