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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER If OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS '��'t�1�, �� . + Y-oeL �G�� <br /> 7 ?C' Street Number Olreetion Street Name Ci Cutle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#i APN# LLANDSE APPLICATION#) 95 o t v SDPHONE#2 EMT• STRICT LOCATION CODE <br /> CONTRACTOR It SERVICE REQUESTOR l <br /> REQUESTOR CHECK If BILUNGADDRES / <br /> Civ l J <br /> BUSINESS NAME re PHONE# / ry _ z C I Ex.' <br /> (J L <br /> HOME or MAILING ADDRESS 0 FAX# <br /> 252-2- [-tYa�Z CCN, ( 61V .-I ! ( 7'MICI S 0220 <br /> CITY �Jr ] 7 _ c .�-e r STATE C P- zip q �.z.l <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, opeerator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENv¢toNMENTAL 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=1y <br /> be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S anFEDERA <br /> APPLICANT'S SIGNATURE: DATE: / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® Q 4gµL <br /> 1f APPLICANT is not the BILLING PAR7Y.proof of authorization to sign is required _ I Titre <br /> AUTHORIZATION 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 enviromnental/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. RAYMENT <br /> TYPE OF SERVICE REQUESTED: R E C T t 1 tM <br /> COMMENTS: e /l � ,lllfllS (il vi.u.. 'P\ AUG 2 7 'l;,A <br /> SAN JOAOUIP! COUNTY <br /> ENVIROMENTAL <br /> HEALIH DEPARTMENT <br /> ACCEPTED BY: n4 - / EMPLOYEE#: 2-67o DATE: 9� Z 7 3 <br /> ASSIGNED TO: re 1i 1-n' EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: S Z P I E:((,26 I <br /> Fee Amount: yb Amount Paid Payment Date -1 f <br /> Payment Type ✓ Invoice# Check# la3 Received <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />