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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST/# <br /> y- (, q Bq <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS (7451 BI-"DT g>AD L-OD ( CIC-24-0 <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) IO- OOK-gyp <br /> Street Number Street Name <br /> CITY L "a�� STATE ZIP C(s Z 37 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2C'9) 32-7- 1375 c519— 140 ,; - / ( _ 1141 ;>5 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR M 1 T <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> p(l.Zon1 f MV2P 20 33¢-GG 13 <br /> HOME or MAILING ADDRESS FAX# <br /> P. o- Bz)x 2-180 34-0—I Z-3 <br /> CITY L-bD I STATE ZIP Q$ ! <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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 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 Titre <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 aOU, <br /> S ,me time it is <br /> provided to me or my representative. (rH�I&IEN <br /> TYPE OF SERVICE REQUESTED: �f �Ij� ED <br /> COMMENTS: -7/-2 19/1 Cy Julv N JOAQUIN 2014 a 14 <br /> �- F• E��x� ����t SQ ASN=C4t% � 4� ENVIROMENHEALTH DFPA,,_,, T <br /> �Di1/�nlJ � 30 yyvtn� <br /> ACCEPTED BY: J r��1 /Lin EMPLOYEE#: DATE: <br /> ASSIGNED TO: V �Y` v EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: s j P E: 2�D <br /> Fee Amount: 2-, Amount Pai �� Payment Date f <br /> Payment Type InS3 <br /> voice# Check# �o � Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />