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SAN JOAQUIN ANTY ENVIRONMENTAL HEALTH DL-..RTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE EQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> 01'111zia '— <br /> � • <br /> FACILITY NAME <br /> ctl Zf <br /> SITE ADDRESS 4/S7 S Oa('('Den fi v L' T7�c <br /> h p� H5 Zo5 <br /> Street Number Directiontreat Na e C Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> al 6 ) 33 6 - o 6 l <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR _ <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME + PHONE# ExT. <br /> �v1AevtcikAwA— vvn,,6 S ) 13C- 3o6-7 <br /> HOME Or MAILING ADDRESS/ FAX# <br /> / <br /> CJ7 5 1 pri • v ( ) <br /> CITY STATE C ZIP q 15 <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 ident' this form. <br /> I also certify that I have prepared this applicati and th the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, and F S. <br /> APPLICANT'S SIGNATURE: {` DATE: ITZ76 <br /> PROPERTY/BUSINESS OWNER LJ 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the s.e it is <br /> provided to me or my representative. + <br /> TYPE OF SERVICE REQUESTED: NI L c <br /> COMMENTS: '"%�Qq <br /> H FNS/Rp�lN Cp <br /> �CTyC pM���N <br /> Nr <br /> ACCEPTED BY: LA EMPLOYEE#: (, DATE: i 2 7 <br /> ASSIGNED TO: V I EMPLOYEE#: v DATE: / <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: (�11 t o 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 />