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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ,Z(I,-' 4 L SEs"I DE A/T/,4L <br /> OWNER/ OPERATOR <br /> IV'�75, t'SS I C /J O� T CHECK if BILLING ADDRESS <br /> FACILITY NAME /`1 <br /> SITE ADDRESS 2 S J�'4S ! �Frrr�/�/ S�ALOti/ g�3ZC� <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#I EXT. APN# LAND USE APPLICATION# <br /> (Zc9�I> q G-c�rg0 — <br /> 300- 13 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> C`! (�SNi= CONSaLTi�IC ( ) lv� 1 03 <br /> HOME or MAILING ADDRESS FAX# <br /> P. O . Oo 4- <br /> CITY L O / �� STATE /'4 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 app ' tion and tha e work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, AT and FE laws. <br /> APPLICANT'S SIGNATURE: DATE: -4 - 2- 3 —0 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/NIANAGER ❑ 10rizTation <br /> HER AUTHORIZED AGENT lLF <br /> IfAPPLICANT is not the B/LLING PARTY,proof of aut 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. N 1 <br /> TYPE OF SERVICE REQUESTED: ft71Z '5-a17-a3111 f-T 5%a D V/E tx/ RFCE4v <br /> COMMENTS: <br /> OUIN COUNT <br /> SA ENv RONMEN MENT <br /> NEAETti DEPAR <br /> ACCEPTED BY: EMPLOYEE#: cr'��elll DATE: <br /> ASSIGNED TO: r/ EMPLOYEE#: f'v&o DATE: .Z 3 <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: lqf� Amount Paid �Cj D Payment Date 4 '3 (a <br /> Payment Type Invoice# Check# � Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />