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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATORCHECKI/ <br /> r\A V\^�eCk k'W Y CHECK If BILLING ADDRESS El <br /> FACILITY NAME Loc[�p e f y A S wmy <br /> SITE ADDRESS 1�p3Sr�3g IuGke�o�� X1523 <br /> Street Number Direction Street Name Clt Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) ( 2 p$ '0 L'Y�Q Pq7 k G YC,C� <br /> Street Number Street Name <br /> CITY rnav tt1clb- STATE ^n ZIP T <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (20`1 > 61a — 30`14 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ////���� <br /> �a VVl vi eek CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> Go ke rd Scdo vvn v1 (20'^1 (2 _ '09 Lf <br /> HOME or MAILING ADDRESSFAx# <br /> (2-OS Lok-u yd P 6q K Ci f d e_ ( 2;e) <br /> CITY Al <br /> a�l—� STATE /'/t zip C15 <br /> 3�3 r-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 <br /> or 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 FEDERAL laws. <br /> APPLICANT'S SIGNATUREx I? j DATE <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT 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 /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available anPAT 1+f4ire it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: CID01O <br /> COMMENTS: 'i:7 <br /> Chary cf Gw(fshlP SAN <br /> ENVIIRONIM NOTALTM <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ,(' ra EMPLOYEE M /'7J � DATE: 24 I q <br /> ASSIGNED TO: V t EMPLOYEE M ✓✓✓V DATE: 2 ' <br /> Date Service Completed (if already completed): SERVICE CODE: , P 1 E: <br /> Fee Amount• 5Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />