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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# =S� <br /> ERVICE REQUEST# <br /> F-��� 2SS53 <br /> tOWNER-1 OPERATOR' <br /> Gi rrt Q CHECK If BILLING ADDRESS <br /> .ACILfrY_NAME �I I� e0 I - 14 �T �� �.�-2 <br /> cSRE�ADDRESS 1 �J (/✓t ((TT (( D <br /> Street Number Dlrectio C t�Q �"Stroet Name �eK�CI ZI -Cotle <br /> -OME_or MAILING ADDRESS (If Different from Site <br /> el Number Street Name <br /> CITY_ - �c STATE ZIP q 3 bI—+ <br /> �P-HONE#1_. EXT. APN# LAND USE AVPP—L�ICATION# <br /> '24) <br /> 2 _)-� - 0 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> ,REQUESTOR _y.IAUr JVIIA Z <br /> t-1 CHECK If BILLING ADDRESS <br /> 'BUSINESS NAME TN` `PHONE#—�'\ EXT. <br /> Lc� vo Gl �a 8 OtJ`f'ZT2 0� <br /> HOME Or MAILING ADDRESS FAx# <br /> VtS (Cl, 9S361 ( 1 <br /> :CITY- STATE (Z( ZIP Q O� <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 /> cAPPUICANT'S SIGNATURE: �DATE:- !O- IC!- 70- <br /> PROPERTY/ <br /> 0-PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization t0 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 t0 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: o A v e h l l� �S G�Ir�� R FcM <br /> COMMENTS: Oct CQ, <br /> �4 <br /> sv,J0.4 ?0?0 <br /> ENI,/0 QJIN <br /> HE9(TN OtN 7y <br /> ACCEPTED BY: V V \ EMPLOYEE M DATE: liD-1_1—2c> <br /> ASSIGNED TO: M EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Q(o PIE: 1 <br /> Fee Amount: Amount Pai /5� v Payment Date /E /� 20 <br /> Payment Type Invoice# ` Check# Received/By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />