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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# FSRO, <br /> ERVICE REQUEST# <br /> ASIDE L 0R 135 <br /> OWNER/OPERATOR <br /> J C� CHECK If BILLING ADDRESS� <br /> FACILITY NAME r V !� '/ <br /> SITE ADDRESS !' D L M jZ A y F— , I S(e Lizry a <br /> y70 -7 � <br /> Street Number Direction Street Name cityZI Cotle <br /> HOME or MAILING ADDRESS <br /> (If Different from Site Address) <br /> F0. &V <br /> '2 Street Number Street Name <br /> CITY STATE ZIP <br /> S 1 LI C K n/ GA <br /> PHONE#1 Em APN# LAND USE APPLICATION# <br /> V- of-c /boa a <br /> PHONE#2 ExT BO$DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / , CHECK If BILLING ADDRESS <br /> BUSINESS NAME n r �^ / / PNONE# ^/ Ex , <br /> HOME or MAILING ADDRESS FAX# <br /> 0- 4 ( ) 41"&l0-Z! 'jg <br /> CITY �T' STATE C^ ZIP <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,StandarMSd4F laws. <br /> APPLICANT'S SIGNATURE: DATE; <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 9WHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY Proof of autA rization 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 t0 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: SurZr-ACIF AND lao5U,-FACt= 6-e10 1n1-1V1}j0A1 .�r"�P 2t=✓/EW <br /> COMMENTS: <br /> f. .� l�m,�� ✓,A� �� � �e�N13 �N <br /> C r <br /> SAN 3OH)p THS PNGES„IOt; <br /> A1[:: �Bn MFt14p1 NEAT, <br /> APPROVED BY: q EMPLOYEE#: ZZ V Z DATE: <br /> ASSIGNED TO: �I` I(Znr EMPLOYEE#: (t0 0 DATE: - 13 <br /> -1 <br /> Date Service Completed (if alr dy completed): SERVICE CODE: 3(S P I E: 2I—, b 3 <br /> Fee Amount: l Amount Paid 2X -�.,_'- _ Payment Date <br /> 611(3 16 PaymentTypeType v Invoice# Check# J�;. i Received By: �_ <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />