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E <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# . <br /> X373 <br /> OWNER r'OPERATOR <br /> 110144 CHECK if BILLING ADDREss <br /> FACILITY NAME <br /> SITE ADDRESS 170 U � <br /> Street Number Direcion Np Code ' <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY t STATE ZIP ?523, <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> t2.oq I 4{01 -9 7 f� /0 S /W -�3 PA - <br /> PHONE#2 ExT• SOS DISTRICT LOCATION CODE " <br /> ( I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> i REQUESTOR � lee <br /> �y CHECK if BILLING ADDRESS <br /> USINESS NAME 1�! <br /> �1 LLp�I � !/�� Ext . <br /> BPHONE# � <br /> HOME or MAILING ADDRESSD, !7'X Z��O Foix# <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 1 <br /> or activity will be billed to me or my business as identified on this form. 1 <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAri JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE�aDERAL laws. <br /> Y <br /> APPLICANT'S SIGNATURE: DATE: <br /> _ <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 tte <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 itis <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: SIl�rrl /�� r r �,A.fyEtd <br /> �TOZ7T RECEC1lE� <br /> z <br /> "114 rouKry-; <br /> _,aIn <br /> .ir.Tav <br /> ACCEPTED B EMPLOYEE#: DATE: <br /> ASSIGNED TO: " EMPLOYEE#: DATE: <br /> AC <br /> Date Service Completed (if already completed): SERVICE CODE: 5-2 P 1 E: <br /> Fee Amount: 2� `i Amount Paid Payment Date 01, 2b <br /> Payment Type ✓ Invoice dheck# kM;�NAReceive'd By: <br /> EHD 48-02-025APR 2 L+ e1o�1 SR FORM(Golders Rod) <br /> REVISED 11/17/2003 U G I <br /> ._ MN JOAQUIN COUNTY <br /> ENVF,0NFAENTAL . <br /> NEAL4H OEFARTry!ENl _ ./ <br />