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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> I Ise-1vic� SROOS 1 a 33 <br /> OWNER/OPERATOR <br /> Z - C- � a V CHECK If BILLING ADDRESS <br /> FACILITY NAME Vt <br /> SITE ADDRESS La Q 5 ZZo <br /> 3 Street Number Direction L I delm. 'KG q Cit /Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) Z;j / UG P,`—r„ /-/\I,\ <br /> 7 Street Number Street Name <br /> CITY La STATE C2 1 <br /> 4- ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (-L'1) S(�--7S 6151- 0-6 <br /> —] <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQy'- TOR <br /> / � CHECK If BILLING ADDRESS <br /> B NESS NAM PHONE# EXT. <br /> or MAU ING ADDRESS FAX# <br /> l�U K l Z ( ) <br /> CITY �<� Y\j STATE e' ZIP Ct Z BILLING ACKNOWLEDGEMENT:ACKNOWLEDGEMENT: 1, 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 applicatiot al hat the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE <br /> APPLICANT'S SIGNATURE: DATE: l e) l� <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT 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 and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> OCT 0 4 zoos <br /> SAN J0AQU11y COUNry <br /> H E'1'nV'1R ONMEN TA I <br /> ACCEPTED BY: Afth EMPLOYEE#: rNT <br /> ASSIGNED TO: 444&:�p EMPLOYEE#: I DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: P I E' �l <br /> Fee Amount: b Amount L10 Payment Date �/ <br /> Payment Type CFS Invoice# Check# 1, Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />