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JAN JOAQUIN COUNTY ENVIRONMENTAL HEALWDEPARTMENT <br /> SERVICE REQUEST <br /> Ty;?e of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OU 5� S <br /> OWNER/ OPERATOR <br /> 16 k L Cf} 7 C— ANE L L/ CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS I(Vr 11'1 rn ey <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) irC iqrm s! p I <br /> Street Number TYUnStreet Name <br /> CITYL O tI STATE ZIP <br /> CA , 'IS Lvi <br /> PHONE#1 ExT APN# LAND USE APPLICATION# <br /> ( o 334 - 065 OSg- 060 - 6/ Ph 0700014 <br /> PHONE#2 EXT SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> C v l L le•. (a ) t t 71— lo 4-2 <br /> HOME or MAILING ADDRESS FAX# <br /> 53. 5 �blar• �c2✓tc!-t �o� • ( ) <br /> CITY L^ STATE< e ZIP 9 vf-al� <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,Standards,S TE and FEDERAL <br /> APPLICANT'S SIGNATURE: <br /> DATE: '1 (o zfl <br /> PROPERTY/BUSINESS OWNERD OPERATOR/MANAGEROTHER AUTHORIZED AGENT <br /> - If APPL/CANTisnottheB/LL/NGPARTY proof ofauthorization 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 ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. JJ�W^ �t ` <br /> TYPE OF SERVICE REQUESTED: �.,v IP.I.V /J I SIJ ITI I1 5`j'VCt PAyTMFNT <br /> COMMENTS: -! gt�ftf� <br /> i LUUJ <br /> S\, , - N COUNTY <br /> LN' - _N'v TMCNT <br /> HEALTH <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE:-e7 11 <br /> Date Service Completed (if already completed): SERVICE CODE: SZ 2� PIE: <br /> 1 <br /> Fee Amount: ''Zro " Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />