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_ I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5,v,00-7176r <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME v*1 D <br /> SITE ADD !S� V <br /> t O(treet Number Direction I ` I"a4-N.meAi Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> P ONE#1 EXT* APN# LAND USE APPLICATION# <br /> 2 ) 309 -(� I� e5S- 1 c�o-7� _ i3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> QUESTO CHECK If BILLING ADDRESS El <br /> INESS NAME PHONE# EXT. <br /> QII (� . s1 X50 SSoc�R�PS X�1 367— <br /> HOME <br /> 67 HOME or MAILING ADDRESS FAX# <br /> CITY / STATE (4 ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agentl 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 /> also certify that I have prepared this applicatio that the to ormed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STA7EdD� <br /> APPLICANT'S SIGNATURE: DATE 3 8 <br /> PROPERTY/BUSINESS OWNER❑ PERATO MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IfAPPLICANT 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It Is provided t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: SSA JL S 7ZA(� <br /> COMMENTS: <br /> MPS 1511-5- <br /> GOv <br /> ACCEPTED BY: �L�c EMPLOYEE#: ATE <br /> ASSIGNED TO: ���—� EMPLOYEE#: DATE: <br /> � b <br /> Date Service Completed (if already completed): SERVICE CODE: �Z P/E: (or7�J <br /> Fee Amount: Amount Paid (� Payment Date <br /> Payment Type Invoice# Check# 0 L l�5� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07117108 <br />