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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or PropertyACILITY ID# SERVICE REQUEST# <br /> CO�,ao5T frciY 7- U- 8cjolyl <br /> OWNER/OPERATOR I /i <br /> 2 ISE S 0 t'� t2 if <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> 12VE5T 0c// iNC- <br /> SITE ADDRESS 91(0 �2� lA/E2T Z-/4 ROP 9S3iO <br /> Street Number I Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) S3 L) 5 <br /> 7-7Z <br /> Erl- <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> 5A N Fe 1,Af cA 94tos- ao�� <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> (5-/0) e47- oo - .260 -9te PA - a oo l/ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR GNESNF CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> ROVO <br /> S F` TCL/f120 N UGT/.J (a2 OZ-/65� <br /> HOME or MAILING ADDRESS FAX# <br /> D 15K RIP, ( l <br /> CITY MODE 5TD STATE /1n ZIP S3 S6 <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 app ' ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, and L laws. <br /> APPLICANT'S SIGNATURE: DATE: l0— <br /> l0— fZ <br /> �3' <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR MANp <br /> AGER OTHER AUTHORIZED AGENT ICS <br /> If APPLICANT is not the BLLLING PAR TP proof of authorization 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 to the SAN JOAQUIN COUNTY ENVOtoNh1ENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. t 1 <br /> TYPE OF SERVICE REQUESTED: �a4 S �-TV.- ( 6 <br /> NTS: <br /> COMM p <br /> ��j��'tr✓�Q�..4' AYMEM <br /> RECE/Vc7 <br /> �D�3 20/? <br /> ACCEPTED Y. EMPLOYEE#: �, <br /> ASSIGNED TO: �_ r— l EMPLOYEE#: DATE: <br /> Date Service Completed tff already complete ): SERVICE CODE: �- P I E:?(PD Z <br /> Fee Amount: 2` `� Amount Paid _,,: -_ Payment Date <br /> Payment Type j Invoice# Check# ),; Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17t2003 <br />