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{ <br /> I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY 10# SERVICE REQUEST# <br /> S�C)a <br /> OWNER/OP ERATO RCHECK If BILLING ADDRESS❑ <br /> P4ju.ip P-7FF;v1�214s;0-0- <br /> f PACIUTY NAME <br /> f SITE ADDRESS 3� Cr�l'v[x`t GW i3 gt�J D. 5�cc�t al•� gS Zo <br />+ Street Number Direction Street Name ZtP Code <br /> HmF or MAILING ADDRESS (If Different from Site Address) AV <br /> Street Number St t <br /> CITY STATE zip <br /> ExT. Apt # LAND Use APPLICATION� <br /> 'ONE /2,1 -030- OS <br /> BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> IftEGIfESTORl �� CHECK If BILLING ADDRE55� <br /> EXT. <br /> BusimEss NAME p /I/(IJ�PF�`� PHa2N�E# 33 ��613 <br /> HOME or MAILING ADDRESS Q, �/ A FAX# rL 7 zy 3 <br /> P 0 Vt7A u��U ( ) 33 7�0/ C�7 - <br /> CITY wp STATE zip Sz r <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> r aeknowledge 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 DERAL la <br /> APPLICA1�iT'S SIGNATURE:, DATE: <br /> PILOPERTY/BUSINESS OWNER 13OPERATOR/NIANAGER [3OTHER AtS7HORIZEP AIG EXT❑ <br /> If IFPLICANT is not rhe BILLING PARTY,proof of authorization to sign is required true <br /> —iJ ORIZATION TO RELEASE INFORMATION: When applicable, 1,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 /> -Anformation 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: N(T)"' <br /> ComllENT5: <br /> 4 s n <br /> 0VA COUN <br /> [X�. AO meNaAt- <br /> �L.f���PAR�M�t3f <br /> t H <br /> ACCEPTED BY: [�L.t U Et EMPLOYEE#: 0 ��' DATE: t Z 0fe <br /> ' AsstGNE4 TO: EMPLOYEE DATE: <br /> CCITD <br /> C <br /> Date Service Completed (if already completed}:-S� SERVICE CODE: X25 P I E:,a p <br /> Fee Amount. S cf� t S- Amount Paid ,5 Payment Date <br /> Payment Type L� Invoice# Check# CSU Received By: <br /> r <br /> EHD 48-02-025 SR FORM(Golder.-Rod) . <br /> REVISED 11t1712CO3 <br />