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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> -F <br /> Type of Business or Property FACILITY ID# SERVICE <br /> REQUEST <br /> /# <br /> 1,9 ENT//-{L <br /> OWNER I OPERATOR <br /> IV,I p LE/A/E 67. Lftu/rOA1 F4ml6 I m 7-ED PgxrA/E2,s//P CHECK If BILLING ADDRESSE] <br /> FACILITY NAME p <br /> SITE ADDRESS 50,W7-lq VE AvE/Vl <br /> S Z 3 Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 203 7A D D/(V y 70 A/ C OG(QT <br /> Street Number Street Name <br /> CITY � NO STATE ZIP ells// <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (775-) e� - X93 119,4 - r!5; � <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR /� <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> ) Z-6s,-14o3 <br /> HOME or MAILING ADDRESS FAX# <br /> O 130 ( ) 7-5;98 <br /> CITY Z-e",-- 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 applic 'on and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST and FED 1 ws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANAGER ❑ THER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of au toriZation 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 /> 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: su2>cq[ A/ Su Sa( F.4 /NAT10// EPO SAY ED <br /> COMMENTS: <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL. <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: C, DATE: 0/0 6 <br /> ASSIGNED TO: - EMPLOYEE#: -5'7Zy L{ DATE: /0 06 <br /> Date Service Completed (if already Completed): SERVICE CODE: (' j P1 E: 2 n <br /> Fee Amount: b ) _O Amount Paid C �, Payment Date 31t o O <br /> Payment Type Invoice# Check# a-y Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />