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SAN JOAQUIN .JUNTY ENVIRONMENTAL HEALTH ,. _'ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �-A o0'2-2cP3Z g�71 l` 0$45V <br /> OWNER/OPERATOR MA12COs 1 D <br /> Wpe CHECK If BILLING ADDRESS <br /> FACILITY NAME ode Pcl c z ���- 2 Z <br /> s� � <br /> SITE ADDRESS y �"+ 'LI/l I� 1 LArIG 1.J jam/ IM OC.� <br /> Street Number Direction t e Name i Zin Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1 13- V� 1z•I �YICL �r <br /> Street Number ✓ Street Name <br /> CITY f�/� �r�e� STATE Mr ZIP �—�55 <br /> PHONE#1 1 1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT11 LOCATION CODE <br /> ( ) <br /> ( CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Love CHECK if BILLING ADDRESS <br /> BUSINESS NAME -.H' �S�la�j—� L� P" 1 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY M o STATE CA ZIP (I �C C <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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: (4.�reD5 1� �a DATE: a Il O 2.r' -Z'0 Zo <br /> I -- <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 environ I19'i to assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available ally C jijn� It IS <br /> provided to me or my representative. `'A1� <br /> TYPE OF SERVICE REQUESTED: V V� li �S �, �� °z^II�I <br /> COMMENTS: &NA V�C F � /1/C <br /> �CTyo pA�OUN�, <br /> NT <br /> ACCEPTED BY: .(�( EMPLOYEE#: DATE: O`-D"L-2)'Lu <br /> ASSIGNED TO: EMPLOYEE#: DATE: U(- V 2_Zon <br /> Date Service Completed (if already completed): SERVICE CODE: PIII E: i Lo <br /> Fee Amount: 0 kc-2, 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 /> S' <br />