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- � � 4: <br /> SAN JOAQUI COUNTY ENVIRONMENTAL HEALTH EPARTMENT <br /> SERVICE REQUEST N-, <br /> Type:of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1 11 % L20 2-1,3 <br /> OWNER r OPERATOR <br /> CHECK if BILLING ADDRESS El <br /> FACILITY NAM <br /> SITEADDRESSLEI <br /> Street!Number Street game Ci Zio Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 12{pt� r�PRf ATG C_{-E-ey— <br /> Street Number Street Name <br /> CITY p y Paf� STATE ZIP <br /> PHONE#1 I�— ExT. App# LAND USE APPLicATION#F <br /> (zo-v 4 357a wi ?.a3- 2.10 --1(c -PA -1000D3l <br /> PHONE##2 EXT. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR , <br /> REQUESTO iI>PrJE: vt1 k.t_Gt'r CHECK if BILLING ADDRESS O <br /> BUSINESS NAMEPHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> �Fo7C7AcK- ST (26'() U04-03` '} <br /> CITYLtia�1 STATE i ZIP 9 q;-1,'+ <br /> D <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 preparedthis applica 'a d e wor e performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Ards, STATE nd RAL laws. <br /> APPLICANT'S SIGNATURE: DATE: _4I <br /> PROPERTY 1 BUSINESS OWNER 13 OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ j <br /> If APPLICANT is not the BILLING PART I proof of authorization to sign is required Tine <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. j <br /> TYPE OF SERVICE REQUESTED: a-F—V t E W S01 LSU%T-N-%St L t-TJ I fJ l fL-'N- c L-o ab�*J Cr SK"v-D4 <br /> COMMENTS: G/,-;,/L1 Q <br /> 1UN 2 2 <br /> , / F <br /> 01y PERMII*Frr:; <br /> ACCEPTED BY: EMPLOYEE#: DATE: y is <br /> ASSIGNED TO: 5 EMPLOYEE�#: b({,� DATE: <br /> Date Service Completed (if already completed): SERVICECODE: �Z� P1 E: 6 p <br /> Fee Amount: S S Amount Paid , Payment Date <br /> Payment Type G� Invoice# Check# Received fiy: <br /> EHD 48-02-025 SR FORM( olden Rod) <br /> RE V]SED 1 1117/2003 <br />