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SAN JOAQUIN COUNTY ENVMONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> y j` W�T La 1 Q C--W`N ( �.IJ CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> K(( tnl T 13Q W I�J 6 -r .2i?O AA <br /> SITE ADDRESS q Z"1er 1.")VU S'T2 to L \-jll�' 1r0 i7� <br /> Street NumbDirection Street Name city Zin Code <br /> HOME or MAILING ADDRESS (If Differant from Site Address) <br /> 155 � �.. 'goccwz� A'JC- <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (530) I 0149 - 160 - 16 <br /> --- <br /> PHONE 92 EXT. BOS DISTRICT l� LOCATION CODE <br /> V <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR V 1..7)—J MAYL CHECK if BILLING ADDRESS <br /> ATL C <br /> BUSINESS NAME PHONE# EXT. <br /> lilC�K lYPr1- iU-�i�� C. <br /> HOME or MAILING ADDRESS FAX# <br /> a / MC-NQOCtl-hD C— ( ) <br /> CITY Tt% ri STATE L./r ZIP CI�Z <br /> BILLING ACKNOWLEDU YLiM: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTmENI-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 JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLiCAYT is not the BILLwG 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 a nt <br /> information t0 the SAN JOAQUIN COUNTY ENVIItONMENTAL HEALTH DEPARTMENT as soon as it is available and at the saq2F i <br /> � <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: �t-AQ C,�AeC_ <br /> COMMENTS: J <br /> iT�IRC ZINC <br /> y�FpgR�,q� �- <br /> ACCEPTED BY: 1'S EMPLOYEE#: DATE: i <br /> ASSIGNED TO: (`�/('� EMPLOYEE#: DATE: �( <br /> Date Service Completed (if already completed): SERVICE CODE C, P 1 E: <br /> Fee Amount: — Amount Paid /� Payment Date 5-131,11 <br /> Payment Type V' invoice# Ch'p&# ^- 7f �c��� Received By:j <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 91/17/2003 <br />