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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SE ,VtIDEQ1,1 E T# <br /> 10 <br /> OWNER/OPERATOR <br /> N ` CU ka- f��Vit' CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME `VJ <br /> SITE ADDRESS //� WDI ecS'{' �-b p4 C,(\C 'L eAv"�� c��23 <br /> _I Street Number Direction Street Name Ci ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (415 ) 23 <br /> PHONE#2� O EXT. BOS DISTRICT LOCATION CODE <br /> (2 ) 26Z <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> N 1,60 ka j "C �^ \`K C' CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. (( �0 <br /> Y22 2-620 yt52,96 <br /> HOME Or MAILING ADDRESS FAX# <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 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. y <br /> APPLICANT'S SIGNATURE: /V 1 t l— S 'r'�--v` J A f J� f� z DATE: T 02® <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APDL/CANT 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 /> 8AIV SANelv <br /> N Ty DNMNOqL 7y <br /> �RTM�Nr <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: CI EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 45� P/E• 0 <br /> Fee Amount: Amount Paid D Payment Date / <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />