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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �u�5� S�C� `0 I � <br /> OWNER/OPERATOR <br /> :1� 0-2- mw MM <br /> BILLIN ADDRESS <br /> FACILITY NAME f <br /> // <br /> SITE ADDRESS ayoc/o ��enc,4 (al)1710 gS23 I <br /> Street Number Direction Street Name Cit ! ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) �.4- <br /> Street Number73a �I Street Name <br /> CITY / STATE ZIP <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> (16YI, ) 4103 -0;13 g <br /> PHONE#i2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR _ <br /> ^ C.2— E` Cr�r <Jc<— <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME r` J 1. PHONE# EXT. <br /> r a 'P 1 , ' ,, (103-U3gq <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY / STATE ZIP <br /> BILLING ACKNOWLEDGENIENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or pro'ject 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 1 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 SIGNATURE: DATE: ! / 0 � 9 <br /> PROPERTY/BUSINESS OWNER❑ OPERA"rOR/ ANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTIIORIZATiON TO RELEASE. INFORMATION: When applicable, I, the owner or operator of the proper located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmen s snicntt <br /> information to the SAN JOAQUIN COUNTY I:NVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at '.AQ/ <br /> provided to me or my representative. 'C�V <br /> TYPE OF SERVICE REQUESTED: 44%10ft / UWI -SqAt 0 <br /> COMMENTS: /S�CNV/Rl C+ <br /> u, ry <br /> FNT <br /> ACCEPT"ED BY: ( C EMPLOYEE#: 1 DATE: <br /> ASSIGNED TO: L <br /> "I/4-01(yr- L EMPLOYEE#: g DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: O/ i P i E:j U <br /> Fee Amoun (�(� Amount Paid � 02,(>(D Payment Date <br /> Payment Type G� Invoice#t Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />