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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or P7� aL'esoo <br /> FACILITY ID# SERVICE REQUEST If <br /> 2 <br /> OWNER/OPERATOR //.j/�Lt `� Dom''- �✓S CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS rosesfS LC.pl <br /> Lf s2 y_ <br /> �- - - Slre Numbe Direction Street Name Cit Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t ENT. APN# LAN USE APPLICATION# <br /> ms <br /> PHONE#Z ExT BOS DISTRICT LoCATlqh6CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME ` PHONE# Ism <br /> o� 33y-G613 <br /> HOME or MAILING ADDRESS � FAx A 2(g p ( ) -3, <br /> CITY L r� STAT 4 ZIP qS 2 V I <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,r..L%'' AT d F AL law,s,/�J� / <br /> APPLICANT'S SIGNATURE: /`� MAC. l DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTRER AUTHORIZED ACENT Er <br /> If APPL/CANT is not the BILLING PAR 7Y 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 enviromnentaVsite 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: <br /> COMMENTS: <br /> Pp(MEHT <br /> pjt?p617 RECEIVED <br /> A/ ' rte" ' APR 0 S 2011 <br /> 'AN,nrIRONMF Tw <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: T 'r DATE: <br /> Date Service Completed (if already completed): SERVICECODE: , PI E. <br /> Fee Amount: -O+ Amount Paid / Payment Date " 7 <br /> Payment Type c; Invoice If Check# Received By: <br /> EHD 48-02-025 SR FORM(Go en Rod) <br /> REVISED 11/17/2003 <br />