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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTNIENT <br /> SERVICE REQUEST <br /> Type of Business or Property <br /> FACILITY ID a« SERVICE REQUEST# <br /> OWNER/OFYRATOR <br /> 1, <br /> CHECK N 81WN0 ADORESSO <br /> FACILITY NAME `14 1/: S o_%Aaaf C A-A <br /> SITE ADDRESS IIID V 1�"` t I Ora. rft, JIOG�Dn ��0-L <br /> Street Number Dlrectlon tree Nerne Zip Cod* <br /> HOMEorMAILING ADDRESS (Ir Different from Site Address) e�.�y� <br /> SJ% Street Number `" <br /> CITY L\\1U-nCkr <br /> TE CPI zip erD <br /> Vl..t'I"10r L l J <br /> PHONE#I E"T• APN# LAND USE APPLICATION# <br /> (415) 451-(A(PU <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> S t1* <br /> Anal^ CHECK ff BILLING ADDRESS <br /> BUSINESS NAMEP E# Err. <br /> �x Color oit��bh /LL-L `Jtt 071-06(p <br /> HOME or MAILING ADDRESS FAX# <br /> H S1'Iu SA L�vt-re'aL- 6A gaSSo ( ) <br /> CITY L„vurmof Q STATE CN ZIP g4�SO <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 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 DATE: /� 7 <br /> PROPERTY/BUSINESS OWNER lE7 OPERATOR/DIANAGER ❑ 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 /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />