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i <br /> 1 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT j <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# /SERVICE REQUEST# j <br /> OWNER/OPERATOR <br /> �, D ,n`^ CHECK if BILLING ADDRESS <br /> FACILITY NAME "[��G <br /> SITE ADDRESS W y4lU 017I It 64 <br /> 4 <br /> Street Number D,rectfon St /City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> '5'Y 2— ffiajipa5ta- R CL f <br /> Street Number Street Name <br /> Cl % STATE ZIP q-�;3 6-q <br /> PHONE#t EXT APN# LAND USE APPLICATION# 7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> t ) <br /> CONTRACTOR/SERVICE REQUESTOR i <br /> REQUESTOR �1 1 CHECKIING ADDRESS <br /> CA Vi CA, C�U y l if BLLA } <br /> BUSINESS NAME n� ^ PHONE J� EXT ! <br /> (D v l 111) <br /> HOME Or MAILING ADDRESS � '^,�llYi S f� F # <br /> CITY STATE ttil� ZIP h}v5 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. 1 <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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �� f DATE: <br /> I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ ' <br /> i <br /> If4PPLICANT is not the BILLING PARTY,proof Of authorization t0 sign Is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property Iggated at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/si"+0ent j�i <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at th <br /> provided to me or my representative. <br /> TYPEOFSERVICE REQUESTED: Al <br /> COMMENTS: F do,Q �� s <br /> y�4Ty�0gMRNO�H <br /> T MHT I <br /> ACCEPTED BY: A1 EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: 10- <br /> -11 <br /> Date Service Complete if already com ed): SERVICE CODE: P I E: <br /> Fee Amount: 1 2— Amount Pal �S� UC/ Payment Date S� <br /> Payment Type Q Invoice# Check# �/ ���� Receiv d By: <br /> i <br /> i <br /> t <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br /> III <br /> I <br /> �a-o5 L1L-i Li�� <br />