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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1 k's <br /> OWNER/OPERATOR /> <br /> `�J\ CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> �� uC�S <br /> SITS ADD C�d�G�G� G`/ �/ LGr�iv� <br /> / Street Number Direction Street Name Cit Zip Code <br /> Hotg or MAII ING ADDRESS (If Different fro—Site Ad � wStreet Number *C/ _ Street Name <br /> CITY STT ZIP <br /> PHONE#') Exr. ApN# LAND USE APPLICATION# <br /> (3/0) qgo-Ss o� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS _ <br /> /` <br /> BUSINESS NAME r' PN # EXT. <br /> — -- �/ .i (U) <br /> FUME Or MAILING ADDRE FAX# <br /> r <br /> CITY STAT ►�y ZIP <br /> Iter/ Vo r <br /> BILLING ACKNOWLEDGEMENT: 1. the undersigned property or business owner, operator or authoa•;zed 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 /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN Jt�Ac)[ IN <br /> COUNTY Ordinance Codcs.SYandarc%s. I and FEDI: s. 2 <br /> APPLICANT'S SIGNATURE: D.ATII:_V_ <br /> PROPERTY/BUSINESS OWNER❑ OPER4TOR/IN'IANAGER ❑ OTHER.uTHORIZEDAGENT91 4-714 <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title PAg <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the propey 4�L*ot <br /> m <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environental/sIiVFIA <br /> information to the SAN JOAQUIN COON-rY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and att j nt time I <br /> provided to me or ni),representative. 4 �9 <br /> Am <br /> TYPE OF SERVICE REQUESTED: e�ek- .� aCu- QltINC <br /> COMMENTS: HDEp NTAL <br /> /-CiJa�f ���/Lat�f aF LC- S�tci/,-hkr�e� �i� :spa, Ega,o�c.•r-� 4�h1i'�, fl✓AC. /•>��T"'EroT <br /> Pa.fi : <br /> ACCEPTED BY: ( ;� C5� O EMPLOYEE#: DATE: <br /> ASSIGNED TO ITL h R v-,./--sI <br /> #: DATE: 7 0 <br /> _ <br /> Date Service Completed (if already completed): SERVICE CODE: Z� P I E: <br /> Fee Amount: z} - — Amount Pai �'g� v� Payment Date �e <br /> Payment Type �� _ Invoice#A Check# 572 eceived By: <br /> EHD 48-02-025 `t ( SR FORM(Golden Rod) <br /> REVISED 11/17/2003 _ <br />