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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/OPERATOR .67;e*�4 .1/uill�Pl�, <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME �j�[ �^ �r <br /> SITE ADDRESSOr /7dg �"'Q ¢tQ��/��7 � gsa3� <br /> Street Number Direction Shee[Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> • 0 0 7 / Street Number Street Name <br /> CITY ,rISTATE ZIP 4!5�vvG <br /> PHUZE#1 4 En. APN# LAND USE APPLICATION# <br /> eel) <br /> PHONE#2 Exr. BOB DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / �yA /f�� <br /> CHECK IT BILLING ADDRESS <br /> BUSINESS NAME y l/n P E <br /> HOME or MAILING ADDRESS �O ' Fax# fj <br /> 33 -d7�3 <br /> CITY STATE e/ 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 <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 and FEDERAL law.5 marl <br /> APPLICANT'S SIGNATURE: DATE: G Ilr Af <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHOR IZE D AG ENf <br /> IfAPPLICANT is not the BILLING PARTY proof of authorization t0 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 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: <br /> COMMENTS: RECEIVNT <br /> ED <br /> JUN 27 [iiia <br /> "AN NV ROMEN JOAQUIN A I <br /> OUNT'y <br /> ACCEPTED BY: rn.. - EMPLOYEE#: � n?o <br /> DATE: 113 <br /> /1 D <br /> ASSIGNEDTO: �'- EMPLOYEE#: 4O DATE: .Zv / 3 <br /> Date Service Completed (if already Completed): SERVICE CODE: 3(5 I <br /> PIE: Z6a03 <br /> Fee Amount: f �-Sb — Amount Paid O Payment Date (01;)--71(3 <br /> Payment Type ✓ Invoice# Check# GJL ,g• Received By: I , <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED11/17/2003 <br />