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SAN JOAQUIN JUNTY ENVIRONMENTAL HEALTH _ .PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -�--k 00,-LZuZS GV- wtkq LA <br /> OWNER/OPERATO <br /> /� t-^II! A Cca I fyl I�`(f & CHECK If BILLING ADDRESS <br /> FACILITY NAME y J r`�r �'.1J ( � -TA(c) ` -r)0vvC�/- <br /> SITE ADDRESS 1 1'2 l` S cl 1`t �`2vl( � S� i(�] q 52� <br /> Street Number Direction , VStreet a cityC de <br /> HOME or MAILING ADDRESS (If Different from Site Address) •201 L41 <br /> Street Number "IStreet Name <br /> CITY STATE/ ^ ZIP <br /> PHONE#1 EXT* APN# LAND USE APPLICATION# <br /> (X" ) <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> EQUESTOR <br /> C,,i �� n 1�� /I� ��i/ 110 , n - $ (CHECK If BILLING ADDRESS <br /> BUSINESS NAME qi ��14 L) ll 1l(� 1-)kl D I WQ(- 4" � 1 ✓/"J P E 2S EXT, <br /> HOME or MAILING ADDRESS FAX# J <br /> CITY STATE OA ZIP ('-1 5-z � 2- <br /> BILLING <br /> BILLING ACKNOWLEDGEMENT: 1, 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, a EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE; 0 ( -Z- - w <br /> :432� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 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, 1, 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. POMFNT <br /> 1 ,� <br /> TYPE OF SERVICE REQUESTED: i�( �V l��QRECED <br /> COMMENTS: <br /> �Cl1MG�(. Q� b�`�Q� .IAN 2 3 21TZI7 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: N n EMPLOYEE#: DATE: <br /> ASSIGNED TO: / 'V EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: V u 1 P I E:I(u3 <br /> Fee Amount: 5 Z Amount Paid Payment Date 2 - <br /> Payment Type Invoice# Chec*# ' u `l U -� 2 ' L F Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />