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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ;2iawt� Tom( bti S"- ) <br /> OWNER/OPERATOR <br /> j1 ti W'A'T't✓a '13,Q L VJ t N C TN C CHECK if BILLING ADDRESSC� <br /> FACILITY{NAME <br /> SITEADDRESS q Z7 1 -1 ,JIDJ 572 ti L V�tf�� UU D---C- <br /> Street Number I Direction Street Name city Zi Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> l55 1S>occt.r,� A C_ <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (5'W) Ll L4(3 - 9 oq1 Det`i - 16f) - 16 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR rn <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# E.T. <br /> HOME or MAILING ADDRESS FAX# <br /> aCtC ( } <br /> CITY Tri C_10 l STATE ZIP Cl 9_4 0 Y <br /> BILLING ACKNO NLEDGEAMNT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENviRONNfEtvTAL 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 this application and that the work to be performed will be done in accordance with all SAN JoAQurN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: �E /i y 1' q <br /> PROPERTY/BUSINESS OWNER kr OPERATOR MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICf1NT 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 ant <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sal <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: L-AW CAO <br /> COMMENTS: (J ✓O <br /> Cil ' '�- �zM ✓ -4 ` n'E94TN" V/iy2 <br /> N pFpMRT � Ty <br /> N <br /> ACCEPTED BY: V� J S L EMPLOYEE#: DATE: <br /> ASSIGNED TO: L% `��:l EMPLOYEE#: DATE: 3t _ <br /> Date Service Completed (if already completed): SERVICE CODE: - ; PIE: /C- <br /> Fee <br /> CFee Amount: - ,, — Amount Paid UD Payment Date S3( <br /> Payment Type `�' Invoice# Check# 4 7376,,/8 7, Received By: /4//� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />