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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Properly FACILITY ID# <br /> SERVICE REQUEST# <br /> RF.S/DENTr 5 L <br /> OWNER/OPERATOR /G <br /> M6 . E✓EL Al CHECK If BILLING ADDRESS <br /> FACILITY NAME l'' <br /> SITE ADDRESS � F2E NGy <br /> 00 Street Number � � �� / •n�TZt/1 %5--13 6 <br /> Direction Street Name Ci <br /> HOME or MAILING ADDRESS (If Different from Site Address) ty Zip Code <br /> CITY <br /> Street Number Street Name <br /> STATE Zip <br /> FPHONE <br /> Eat. APN 0 LAND USE APPLICATION A <br /> PBZ " 033 - O^ Z h - - do0 <br /> Ea*• BOS DISTRICT _l LOCATION ODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR /J�� __ 11 J� <br /> D o V GHeE r= CHECK if BILLING ADDRESS 441 <br /> BusikEss NAME I� <br /> 5 G�nlic ,�l PNONE# I O3 E.,. <br /> HOME or MAWNG ADDRESS FA%# <br /> x ( ) (O!!/t/- Z �/� <br /> CITY L6 _ <br /> STATE ZIP S <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 1 have prepared this appl' •on and that work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S and FED s. <br /> APPLICANT'S SIGNATURE: DATE:_ �¢0-.5- <br /> PROPERTY <br /> PROPERTY/BOsrNEsS OWNER[3 OPERATOR/MANAGER ❑ O R AUTHORIZED AGENT[3 <br /> If APPLICANT is not the BILLING PARTY proof of authors tion 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 rise ent <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and E[ttlGt is <br /> provided to me or my representative. F �/�.1 � \j f-7 <br /> TYPE OF SERVICE REQUESTED: S'c)t L_ <br /> COMMENTS' _ <br /> 1 -1 � F--E-�V � I� v <br /> in COON <br /> JOAQUIN ANAL <br /> SPJEN,&014 Mo <br /> TME <br /> NN <br /> Dep <br /> J , T <br /> ACCEPTED BY: ©(�f VE l e—ry EMPLOYEE#: / DATE: <br /> CO3 z <br /> ASSIGNED TO: 14 u ,.jS EMPLOYEE#: v /r DATE; 1 D� <br /> Date Service Completed (Malready�e/otnpleted): SERV CoDE: s2a �7z p/E: p/ <br /> Fee Amount: - e& Do 2�tj7y amount P -43 7a. �� Payment Date <br /> ment T •3 1 C .r <br /> PaJ <br /> Y Type Invoice# Chec <br /> �'�(p Received By: -,� <br /> EHD 48-02-025 4 ;ou,r SR FORM Rod <br /> REVISED II/17/2003 �n `- , ( ) <br />