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M <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS❑ <br /> f w <br /> FACILITY NAME <br /> VOA <br /> SITE ADDRESS <br /> Qc GtV•, ,�) marl: cty I T4�y � 53c�y <br /> `�JD Street Number Direction treet�Name ' Ci Zi Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) t <br /> ti� v treet Number + ` StreetName L <br /> CITY � � I STAT 0 Ztp <br /> IT— 3 70 Y <br /> I <br /> PHONE#1 ExT• APN# LAND USEAPPUCATION# <br /> (2.�oF) -3--17 - Cali v 2t 1 <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> '-le 4 <br /> `� ouSstf- CHECK if BILLING ADDRESS <br /> 13 <br /> BUSINESS NAME PHONE# EXT• <br /> �T i- f.c: 2og� <br /> HOME Or MAILING ADDRESS G� i FAX# <br /> CITY Jr �l STATE _0 ZIP Q 7 rC <br /> BILLINGACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTx 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. p Jf <br /> APPLICANT'S SIGNATURE: DATE: o i 1! L <br /> t , <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR PAGER ❑ OTHER AUTHORIZED AGENT Q- P--j r n a--'Ci <br /> If APPLICANT is not the BILLINGPARTY,proof of authorization to sign is rewired 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 environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sft-w time it is i <br /> provided to me or my representative. n M T <br /> TYPE OF SERVICE REQUESTED: V1 <br /> COMMENTS: w� <br /> Q�l <br /> -2 Ham^yD�VT <br /> NT� <br /> �FNT <br /> ACCEPTED BY: \� h�l; � EMPLOYEE#: DATE: <br /> ASSIGNED TO: y LA nav n EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Z� P J E: <br /> Fee Amount: ( r _ Amount Paid 7 \ 6 Payment Date <br /> 1 n <br /> Payment Type Invoice# Check# 3 Rec ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />