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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> R�T� e-L A <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> $ALP�SI AKCLE- <br /> FACILITY NAME _( Q S �E LL <br /> SITE ADDRESS l �/Vl 0 R E Arg'k-) G T- S TO C Iz- ro f'( g r Z r Z- <br /> -+C C Street Number Direction Street Name citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) ./ <br /> 3 5 5- Q t� A V A L M ` Street Number Street Name <br /> CITY STATE ^ ZIP / 7 S / <br /> �tZ-E Nn o�� /-t �l7 <br /> PHONE#1 E)cr• APN# LAND USE APPLICATION# <br /> PHONE#Z ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR '^, (^I, ^ L / / A LT o,( CHECK if BILLING ADDRESS <br /> PHONE# EM' <br /> BUSINESS NAME ( t /� -�O�( E,E (� I ►�( E�(2 L�(Ct, <br /> Vv gt6 34-3 1( y <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE C A Zip S6 Q 1 <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 a d that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST and ERALjs. <br /> APPLICANT'S SIGNATURE: DATE: 0-6r- ® 3— <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® O I`c` fZc 2 <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. N <br /> TYPE OF SERVICE REQUESTED: ( A,( G E V(.E LA J EGE1v <br /> COMMENTS: <br /> COVNV <br /> SAN SOP pN`MENTA�N.f <br /> N�USIH�EPPaSM <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: . �� EMPLOYEE M lllttt�i/,q7 DATE: / <br /> Date Service Completed (if already completed): SERVICE CODE: f P/F' <br /> Fee Amount: z Amount PaidS . Payment Date <br /> Payment Type Invoice# Check# g 5 y Received By: C4 <br /> EHD 48-02-025 ^ SR FORM(Golden Rod) <br /> REVISED 11/17/2003 v <br />