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SAN JOAQUIIv i OUNTY ENVIRONMENTAL HEALTH iiEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1��Arl& Go sgx t'sF S,4k-ES _A U b L�q � __ <br /> OWNER/OPERATOR <br /> r � CHECK if BILLING ADDRESS E] <br /> FACILITY NAME M n, r� C A ' VA Lr-R0 Tp—oL—C.V ��l <br /> S TE ADDRESS Street <br /> N 1 tW (� i,rt C Sl 195 334 <br /> r Street Number Direction Street Name cityZi Code <br /> HOME or MAILING ADDRESS Different from <br /> �Site <br /> �Address) <br /> (;07 1 V r Street Number Street Name <br /> CITY r^^Q�Es STATE CR ZIP �f5�s c) <br /> PHONE r#11' ExT• APN# LAND USE APPLICATION# <br /> 94) 5 ?- 6��( a <br /> PHONE ExT• BOS DISTRICT LOCATION C DE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME P NE# E/xT' <br /> b <br /> HOME or MAILING ADDRESS FAX# <br /> S oAla, ) - 93�r � <br /> CITY CEi STATE 'C�4 , ZIP Q'E�:�;4Z�-7 <br /> BILLING 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 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: I J.4 DATE: <br /> PROPERTY/BuSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: PA'WENT <br /> RECEIVED <br /> FEB 11 20 <br /> P' lum GOVtm <br /> ACCEPTED BY: C EMPLOYEE#: DEiLliJ1 D <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 1 GL P/E: <br /> Fee Amount: "C, V Amount Paid A b Paymlent Date a ntS <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />