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SAN JOAQACOU <br /> NTY ENVIRONMENTAL HEALTH EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> AUTC RE rA I R Oio r CAA SCC 2-18 49-1 S f un ,3 ?� <br /> OWNER/OPERATOR KF—Vi N ECKN� h ` t CHECK if BILLING ADDRESS <br /> FACILITY NAME �C 6 w t f, i U 9 r1"� NTU,1 E <br /> SITE ADDRESS �n.I �)l✓ L L��tF-eirT LA T-C e KTCN q5�(C <br /> Street Number �irection Street Name TCit Zi 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 /> (269) 4`13--4 5o <br /> PHONE#ZEX BOS DISTRICT —] LOCATION CODE <br /> (zcq )4-1 - 01 z FAX <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQU ESTOR PA e,, L- [t P1 <br /> N'T-C CHECK if BILLING ADDRESS� <br /> BUSINESS NAME 1 E _ /1ti�7/� UTITE l EXT. <br /> l� !l l..l. PH�� S 59 - 3 49 6 <br /> HOME or MAILING ADDRESS FAX# -I b <br /> L ^ (65(7) `152 <br /> CITY 0C- `5AN 1 rl NCI S CC STATE cA_ ZIP 94c Sc <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 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 a FEDERAL laws. <br /> �� — <br /> APPLICANT'S SIGNATURE: FA- �� DATE: 04,p <br /> PROPERTY/BUSINESS OWNER❑ OP BATOR/MANAGER ❑ OTHERG UT O W IZ GENT I �L`y E GT I4A E e_ <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 same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: 1 EMPLOYEE#: 3SD DATE: <br /> Date Service Completed (if already co leted): SERVICE CODE: G PIE: <br /> 0 <br /> Fee Amount: 2 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 />