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SAN JOAQU. —OUNTY ENVIRONMENTAL HEALTRWARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -FA Y2, Cc,-Z ILA <br /> OWNER/OPERATOR ' ^ r/ <br /> LI� ' vv1 rd A C WA YIrl V-y,Ln - L; lJ CHECK If BILLING ADDRESS O <br /> FACILITY NAME MC rZ k S C© Is 1 ' 1 V1� v- -�a� 1 4V C A Z`I 53--� <br /> SITE ADDRESS �—LAL�l7 S /�;C—V 0 n .� , 1� GJ G� 5-2-DW <br /> Street Number Direction I-S Street Name�N Cit 1 ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) 22Lt v T i4 YZ(Y1 <br /> Street Number 1 r' Street Name <br /> CITY � � STATE 0,' ZIP <br /> PHONE#1 E.T. APN# LAND USE APPLICATION# <br /> ([rU�> SOo1- lP� �lP <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Lt 5 CA,Gy� lC 0\[A�C LA b1 I ` S ope CHECK If BILLING ADDRESS <br /> BUSINESS NAME �(\Lj� rn�� C61�l� 1✓� A2G,C 3_ PHONEto ?SoExT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY S STATE ZIP <br /> CISZv(4�) <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,Standar ,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: Iq <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> /f 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 environme�I1t'all/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and elrll ame time it is <br /> provided to me or my representative. IA- <br /> TYPE OF SERVICE REQUESTED: T WU V e'V i(('`,e /�I <br /> COMMENTS: l/V\V oc� (� Ot✓� i�`�t/LU� y O,gQ(/ �0,9 <br /> TOIRVC <br /> TMFNrI. <br /> ACCEPTED BY: �Q EMPLOYEE#: DATE: ,2 13 IG1 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: U LC P 1 E: C)5 <br /> Fee Amount: 11-1i, 1 C'Z _ Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />