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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> t a �� � kcbls I D-0 9 <br /> OWNER/OPERATOR <br /> V/ <br /> /r CHECK If BILLING ADDRESS <br /> fj <br /> FACILITY NAME 'J Q A , �'l�/��) <br /> SITEADDR�E'ySS rI / ',"1 CST l � �TOck rC� �S��� o <br /> v Street Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site <br /> �cAddress) <br /> C- ►�+ aR. Street Number Street Name <br /> CITY �/ y�t' i <br /> TE Zm- <br /> 1 CL`--ro P TA <br /> -{ C S Z 1 9 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 201) 262-9 110 0 <br /> PHONE#2 Qd EXT, BOS DIST I LOCATION CODE <br /> �� dg 0 / <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ^ /� /� ' J /l 1 , yJ CHECK If BILLING ADDRESS <br /> BUSINESS NAME/f 1� ^ I Y` LL (q` �J 1� PHONE# EXT. <br /> ARV1L-A <br /> HOME or MAILING ADDRES FAx# <br /> ; A)(- <br /> CITY �C C �O STATE ZIP C2-1 <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 <br /> PROPERTY/BUSINESS OWNER❑ ERATOR/MANAGER� OTHER AUTHORIZED AGENT-9 <br /> If APPLICANT is not the ILLING ARTY,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/ ' assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at tle it is <br /> provided to me or my representative. �+ <br /> TYPE OF SERVICE REQUESTED: 058 ��J Sep �® <br /> COMMENTS: H �VOgQU/ 0 <br /> 0 <br /> 1,9 <br /> �Ty�Fp,�FNTOq��N�Y <br /> MFNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: ,I <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if Iready completed): SERVICE CODE: D I PIE: o� <br /> Fee Amount: ,GJ Zoo Amount Paid /'S--�2,D0 Payment Date �2 <br /> Payment Type Invoice# Check# 'ZZecei ed y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />