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z <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> TypL-of Business or Property FACILITY ID# �� SERVICE REQUEST# <br /> Z <br /> OWNER/OPERATOR A OO 0 o 07,K <br /> CHECK if BILLING ADDRESS <br /> 7/// r <br /> FACILITY NAME • <br /> V SITE ADDRESS �;tre4ame <br /> e-(V� / (��7-37 <br /> /L Street Number Direction 4^ �L Cit CZ T Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'l EXT. APN# LAND USE APPLICATION# <br /> (749 ) 7Z7- 5D <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAMEJ 5 PHONE# EXT. <br /> G r s &4,3-677s- <br /> HOME <br /> -5 7 <br /> HOME or MAILING ADDRESS _ FAX# <br /> 12-9 24 <br /> CITY / () / C STATE ZIP S 23 7 <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: DATE: 1-3 -2 G, z0 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER r7f 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: dW T t-re,✓' RAJ Q 4f 5 e� CJ f K1 TG-h LJ 'J TV✓ —1�/� �� �e, �® <br /> s��oq/M 3 ?020 <br /> FN QU/ <br /> NF'qL y0Op4 Z 4 <br /> FN <br /> ACCEPTED BY: cc y V k S oo EMPLOYEE#: DATE: <br /> ASSIGNED TO: ' L c(Q EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: L1 G/ P 1 E: <br /> Fee Amount: Amount Paida Payment Date r <br /> Payment Type Invoice# Check Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />