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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT jI c)U <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVIC <br /> W lrVefl . . <br /> OWNER/OPERATOR ifHIi-ONO RE <br /> FACILITY NAME <br /> Fri _ <br /> SITE ADDRESS )7" C S j e7" �Z o <br /> jzlpan/ 953�(� <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING,ApDDRESS (If Different from Site Address) <br /> SJ/ Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE V i EXT. APN# LAND USE APPLICATION# <br /> ( 1 <br /> PHONE#2 Exr• BOS DISTRICT LOCAnoN CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR .� „ ) �� CHErK if BILLING ADDRESS 1 <br /> / yG J <br /> BUSINESS NAME - PHONE# <br /> HOME or MAILING ADDRESS - FAX# C ! CD <br /> j31 O�/5l�/iL E <br /> 52- -Z30 yo— <br /> CITY ES/� STATE Q ZIP 3 S, rn <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,STATE and FE ERAL laws. <br /> APPLICANT'S SIGNATURE: /��C/f� l DATE; <br /> PROPERTY/BUSINESS OWNER❑ OPE TOR AGER ❑ OTHER AUTHORIZED AGENT (� <br /> IfAPPLtCANT 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 environmental/site assessment <br /> infom'mtion 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: ecy/VS✓-cL- T-47-L' j r 41 U-')A <br /> COMMENTS: „`/ <br /> tf� 2cF\! tF S�PPGv �(s) GtYcAN� S (Sf`EM ARE <br /> F-0 2 ccs E OnJ /U F—ctJ Lo¢-A 0F/--c cF— ,3 t o 6� , 2005 <br /> o6sec-4V471o,.J of= 77E SAN JOAQUIN COUNTY <br /> ACCEPTED BY: OLIve-(44 EMPLOYEE#: G3Z/ DATE: H [Ep�RTME <br /> NT <br /> ASSIGNED TO: VA") 67 rJ£ EMPLOYEE#: 16800 DATE: <br /> Date Service Completed (if already completed): SERVICECODE: m j PIE: L�Z ,Oy <br /> Fee Amount: - 0 D Amount Paid -4 13, p D Payment Date G OS <br /> Payment Type I/ Invoice# Check# Received By: 2Z-�, <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />