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SAN JOAQUIN COUNTY ENVIRO;VMENTAL HEALTH DEPARTMENT , <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAM <br /> Z 1 VL <br /> SITE ADDRESS/' / -o _ . ��a � j� t �/�..,-ly\ <br /> lG�S�treVet Number DirVe tion 9(tr�eetf Name J r`-, city Zi Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CIN �� STATE � L..r-L)� <br /> PHONE#1 /' EXT' APN# LAND USE APPLICATION# <br /> (zm ) 6 - 'UJ2IZ) . 0-70 U <br /> PHONE# EXT. BOS DISTRICT LOCATION CODE <br /> LLyS L 12 -4443 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR t T CHECK If BILLING ADDRESS <br /> BUSINESS NAME V PHONE# EXT. <br /> HOMEor MAILING DRESSFAX# <br /> 30 <br /> `3 avi ) ub7 - C63 <br /> CITY STATE ZIP QC - C?9 <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,Stan S, ATE DERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: I O <br /> PROPERTY/BUSINESS OWNER 13 PERATOR/MAN OTHER AUTHORIZED AGENT <br /> IfAPPLICANT is t BILLINGPARTY 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 assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: 9i,4,-rA-Fji YAY <br /> COMMENTS: <br /> h55/ZEXx9TlQ�7/Csz�/�J itJLS12E�!Wt7RUV2o.t» /bw-:xo -44007 0IV6107 <br /> AY " <br /> IG <br /> J E&M ENTAL COUNTY <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: 1 .EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: S Ub Amount Paid SPayment Date `-7 p,--7 <br /> Payment Type y CSS&A Invoice# Check#�yn3f�� rb S Received By: —/ <br /> EHD 48-02-025 `" I O SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />