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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> _ S12CX� s�,4- <br /> OWNER/OPERATOR <br /> IZ2�/ I I^ CHECK If BILLING ADDRESS <br /> S�AFACILITYNAME /S `-IF 2-11 <br /> � <br /> SITE ADDRESS <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 130 G e L 2 4z- 10O 1�[ 1 Street Number Street Name <br /> CITY —. STATE ZIP q <br /> "L-fly—L/ CIA f <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> Qv) ) H1-SU-I <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR (/�� <br /> CCes -De 0n9r^n\S CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> ZZa 7a-TI(, ;tS "( <br /> HOME Or MAILING ADDRESS 1 T Sl/ Cee(z �,o " i '' '5 FAX# <br /> / �lJ lC l _1 ( ) <br /> CITY 4�)C V� STATE C1�1 ZIP 9 E 3 gZ <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 or <br /> 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: �Z//V'` DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required Tirle <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assest information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It IS prC j11e Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> SAN 4 ? <br /> .p� / � 6,07 589 h TSR NM CO�19 <br /> l FNTA� <br /> ARTMFNT <br /> ACCEPTED BY: 1A La EMPLOYEE#: DATE: J 1C� <br /> ASSIGNED TO: coEMPLOYEE#: Q ^ DATE:2 IJ l I I ' <br /> Date Service Completed (if already completed): SERVICE CODED: ✓ P I E: <br /> Fee Amount: 5 I (�U Amount Pa' — v Payment Date <br /> Payment Type Invoice# Check# � 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07117i08 P�05'f`f l0 5 <br /> S <br />