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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> CAO <br /> I� <br /> OWNER/OPERATOR oLryl 4 Wo I / t�It)U CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME 6)01J V <br /> SITE ADD1RESS. <br /> ` l Street Number Direction Street NamJa CI JZIG Codo <br /> HOME Or MAILIN ADDRESS�y(i(if'ccDi`fferent from Site Address) <br /> 2 %'JJ Street Number Street Name <br /> CITY C-IMt C.P, n^ S_lK_�17E ZIP <br /> PHONE#1 En. APN# `� l LAND USE APPLICATION# <br /> PHONIER EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Ww\a CHECK if BILLING ADORES <br /> BUSINESS NAME V` ` # I PHONE ^ _U�I1 En. <br /> N i (In l� <br /> HOME or MAILING ADDRESS FAX# <br /> `L %S ( ) <br /> CIN Aa U G( STATE�)—\� ZIP Ot '2� <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,S ATE and EDE laws. <br /> APPLICANT'S SIGNATURE,� DATE: <br /> ROPERTY/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,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 environmentaVsite assessment <br /> information to 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: I (L Su n <br /> COMMENTS: <br /> RF4"EM�O <br /> cw(�t GF GW rlers�� l� oEc <br /> �7JOgQU <br /> ALAACCEPTED BY: I /( Q1 EMPLOYEE#: �T6 flFP <br /> ASSIGNED TO: • EMPLOYEE#: J DATE: C/V)' <br /> Date Service Completed (if already completed): SERVICE CODE; P/E: IW5 <br /> Fee Amount 5 ✓ 1 Amount Paid s Z. _ Payment Date l2—h-7 ZO <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />