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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# RVICEST# <br /> I)Cr n5�vmo <br /> OW ER/OPERATOR <br /> -O k CHECK If BILLING ADDRES <br /> FACILITY NAME l� f 1 llh�� r r 1/� ► I <br /> SITE ADDRESS 31/i 1 1 'SCv p rz� X53(71+ <br /> Street Number Direction Street Name / Zi Code <br /> Q(HOME Or MAILING ADDRESS If Different f om Site Address) l l®D N l �)ri s nw <br /> 1 1 Street Number Street Name <br /> CITY r STATE ZIP <br /> C <br /> PHONE#1 EXT. APN# LAN USE 4PPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE 57 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME z5 4 Q _ 2 i �I Exr. <br /> HOME or MAILING ADDRESS FAX# `Tl�c� J f <br /> ( ) <br /> CITY STATE 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 <br /> or activity will be billed to me or my bus[ as identified on this form. <br /> I also certify that I have prepared this ap i ti a that a wor t be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, AT an E laws <br /> APPLICANT'S SIGNATURE: DATE: -1 D C1 <br /> PROPERTY/BUSINESS OWNER OPERA R MAN O ER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT not the B/CLING P RTY proof of au a on 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> CNM COON <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> F <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: D Amount Pa _30Z/. 62) Payment Date ' 7 <br /> Payment Type Invoice# Check# 7/ Received By: <br /> f <br /> EHD 48-02-025n � �1/�, SR FORM(Golden Rod) <br /> REVISED 11/17/2003 I f,, m I �J11 <br /> � V <br />