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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> t S�V <br /> OWNER OPERATOR <br /> Ar. CHECK if BILLING ADDRESS <br /> 7� �C,�{ �� 't F�r=:J SC .1.��L_ �I,TC=i�'i' <br /> FACILITY NAME <br /> SITE ADDRESS ` ��CN ILS AJr1 U MA,rrtEC f1 33 <br /> U Street Number Dlrectlon Street Name city ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> C) v Street Number Street Name <br /> CITY STATE ZIP <br /> 1\,1CA Ch q S3 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> (L EtJ 4 1:-�L L��!`-�V-, 'z FI R IV - w�i t'�T <br /> BUSINESS NAME PHONE# EXT. <br /> MC2 -r 0-3 -U Zz <br /> HOME or MAILING ADDRESS FAX# <br /> 2-I L (Z1u ) <br /> CITY IJ1ASTATE ZIP <br /> �T [R 04- S 3.3 Cc' <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: /�" C G� DATE: 2— 52 Z <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 0 ,V cNC,IN;761'-- <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: �o <br /> EC�B�/FD <br /> FEB 5 200 <br /> S Nj0AQUi1V Co <br /> N1 <br /> HEALT RONMENT y <br /> ACCEPTED BY: EMPLOYEE M DATE: ENT <br /> ASSIGNED TO: EMPLOYEE M DATAD <br /> . <br /> Date Service Completed (if already completed): SERVICE CODE: P/ : <br /> Fee Amount: Amount Paid �- Payment Date C!'o <br /> /ttgo . I <br /> Payment Type r A Invoice# Check# la Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />