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SAN JOAQUIlY-f-' )UNTY ENVIRONMENTAL HEALTH-iQLCPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Sk'.o04�oq-.2/ <br /> Q Ricuc L- &E��si i I- <br /> OWNER I OPERATOR CHECK If BILLING ADDRESS❑ <br /> 6FOUze 1VAoqA!5 <br /> FACILITY NAME N^ 3—A <br /> y 7�7� <br /> LOD <br /> SITE ADDRESS /117.0 f!F/`gJ7S N/4 ,J A. / 0/V'� N•� • l Z� <br /> Street Name Cl ZI Code <br /> Street Number Direction ,I� <br /> HOME or MAILING ADDRESS (If Different from Site Address) //7 Sf iy . J—Acilt 7DWE <br /> Street Number St et Name <br /> ZIP <br /> CITY STATE <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (109) P - <br /> PHONE#2 Ear• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> 0 Ea <br /> BUSINESS NAME ^ r PHONE# a3 <br /> (; L oNSu[T Al l dg'I <br /> FAx# <br /> HOME or MAILING ADDRESS ( ) <br /> P. p . i3ox <br /> CITY 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 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, ST E and FE �L laws. <br /> APPLICANT'S SIGNATURE: 7 14 <br /> DATE: <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, 1, 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 environmentaVsite 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: 50 L A PPY VErt� <br /> COMMENTS: (� 3m �1 LO1U V <br /> SPNE3ON0 me ,Nle v <br /> / EMPLOYEE#: DATE: <br /> ACCEPTED BY: <br /> ASSIGNED TO: <br /> EMPLOYEE#: DATE: <br /> c_ <br /> Date Service Completed (if already completed): <br /> SERVICECODE: J Z Z PIE: <br /> Fee Amount: Amount Paid 30 — Payment Date ✓� /1 b <br /> Payment Type Invoice# Check# 3 1 /2-14Received By: r <br /> Y ,j <br /> SR FORM(Golden Rod) <br /> EHD 48,02-025 <br /> REVISED 11/17/2003 <br />