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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -:;,K -711 1-1 <br /> OWNER/OPERATOR ✓� <br /> / L/( �� /�C- CHECK If BILLING ADDRESS <br /> FACILITY NAME (001 " V �� 1 <br /> SITE ADDRESS W�09 ✓ � v i� T ��7�/!D <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 0 G)�/ M f(i ( VICAO <br /> Street Number Street Name <br /> CITY VL N nr_I STATE _ ZIP &) Z5�3 <br /> PHONE#1 IDEA <br /> Jrj/V Ex'. APN# „ LAND USE APPLICATION# <br /> '00 <br /> PHONE#2 EXT. BOS DISTRICT LOCATIS]N CODE <br /> ( ) do C 4- <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR �-A ` V-F— (/�� <br /> l CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# ExT. <br /> P t LIWA NWYLfai 3 -3+-6 r_/3 <br /> HOME Or MAILING ADDRESSv FAX# <br /> 16J u. Zx Z� ✓L) 3.3j 4-- a7,-3 <br /> CITY ! 17t�I STATE 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,S'rIATE a L laws. <br /> APPLICANT'S SIGNATURE: DATE: 12 ” a1 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY 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 environmentaUsite 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: �w,r Ci .Yt/li� C�Y t <br /> vV V' <br /> F IV <br /> COMMENTS: ENT <br /> 4 t-.1r- RECE VEE) <br /> )2EPC✓Er7z�tGticy ,�,,,� , DEC 1 2014 <br /> /YJ. [JIZO �'` SAN Jo QUI <br /> C� <br /> EN COUNTY <br /> C AUNTY <br /> ACCEPTED BY: M /t fes/ EMPLOYEE#: DATE: q •� I "ENT <br /> ASSIGNED TO: r EMPLOYEE#: DATE: l <br /> Date Service Completed (if already completed): SERVICE CODE: ` P 1 E: <br /> Fee Amount: ,- _ Amount Pais! �� � Payment Date -?/4 <br /> Payment Type Invoice# Check# 5-60 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />