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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> a 6)�)09q -715 I S K00� )15-r <br /> OWNER i OPERATOR <br /> Iv 0 � �� � % t-'( 6N CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS S —1 W ✓ R M I- 1< J R f3 LVA S'r'o <br /> Street Number I DI ect Street NAM— cityZip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Ll -1 1 i-1 [3 r/V A/C-- 7-9 MI LL- <br /> �- <br /> Street Number Street Name <br /> CITY 5 STATE ZIP I�Z <br /> PHONE#'I ExT• APN# LAND USE APPLICATION# <br /> -7 2 q S S— man P <br /> PHONE#2 0-8 �L{0 S <br /> ExT, BOS DISTRICT LOCATION CODE <br /> 2 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR /1 1 1(�( S1 / I CHECK if BILLING ADDRESS <br /> BUSINESS NAME /l�Iv�l(/ I\r/ A i7 V1- I PHONE# EXT. <br /> -72-c— 1 s�5`-2 <br /> HOME or MAILIN ADDRESS FAX# <br /> LI-))%-I � 1=NNL�S 4`1J- LL CT- <br /> CITY <br /> ICITY ST6L r T 0�j STATE bi ZIP C'5Z i <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. <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 <br /> ^"and <br /> ,,--1FEDERAL <br /> ,Qlaws <br /> APPLICANT'S SIGNATURE: ` DATE: c' 0 2-- 2-0 <br /> ROPERTY/BUSINESS OWNEYO OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environment al/s to assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at thealtme it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: O/ t <br /> �vI <br /> COMMENTS: 1-1qO <br /> 10 <br /> jIV C <br /> T/y�pq F' o uN7Y <br /> J 1 Rr,�FNT <br /> ACCEPTED BY: t ,/W EMPLOYEE#: a0 DATE: I 2 <br /> ASSIGNED TO: Ma EMPLOYEE#: '3-3,U/ DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: j lvL, <br /> Fee Amount: 15�'Q� Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />