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"t— SAN JOAQUIN r-)LINTY ENVIRONMENTAL HEALTT- v�EPARTMENT <br /> SERVICE REQUEST 'Woo <br /> Type of Business or Property FACILITY ID If SERVICE REQUEST# <br /> SI Jr--N-F1 S'2 003154- <br /> OWNER/OPERATOR <br /> CHECK ItBILLING ADDRESS <br /> EE�rzA (-D - 2 k) 7 <br /> FACILITY NAME <br /> SITE ADDRESS � � �� L SToacTo Al <br /> 9 <br /> 1 3 Street Number OIreetlon Street Name CI Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> • O ( fStreet Number Street Name <br /> CRY 001 Sr ZIP <br /> PHONE#t Exr. APN# LAND USE W1'7CATION# <br /> PHONE#2 Ev. BOS DISTRICT LOCATIO OOE <br /> ( 1 <br /> CONTRACTOR/ SERVICE <br /> REOUESTOR <br /> Zoo Al CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE If Eta. <br /> G yNfx CaN1c��i/.v <br /> HOME or MAILING ADDRESS FAX# / <br /> CRY /2 LQ G/L STATE C Zip 6-S 36/ <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 /> 1 also certify that 1 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,STA d FEDER Ws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> yy �d/'7/0 Z <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTII AUTHORIZED AGENT yp <br /> If APPLICANT is not the BILLING PARTY proof of authori tion rO sigh 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: Stl'Rl,:�,gCE /1-rV6 SbI SSd!/2F/(-cE Ciyn/ik T+'1f 4T/cJ/V {�02TVIED✓ <br /> COMMENTS: ii �/�-5�.3 RECEIVED <br /> OCT <br /> QUI <br /> SAN J P' TH SERVICES <br /> Pt <br /> l,--r' !r 'r"„'/�•� f HEALTH DIVISION <br /> � DNMEN <br /> APPROVED BY: EMPLOYEE#: ��8 /i DATE: 10-1-7—OZ <br /> ASSIGNED TO: �JC O/r���' EMPLOYEE#: 3 40(p DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PI E:—,:e �2 03 <br /> Fee Amount: 17eo0 Amount Paid ;?Cr eo Payment Date to //-1 t D7-- <br /> Payment Type Invoice# Check# Received By: . <br /> EHD 48-01-025 SERVICE REQUEST FORM/I <br /> REVISEd 6-5-02 <br />