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SAN JOAQL.N COUNTY ENVIRONMENTAL HEAL&EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> e "f�-A(off <br /> OWNER I OPERATOR <br /> ' CHECK If BILLING ADDRESS <br /> e,vl V,1 b\ <br /> FACILITY NME <br /> �- eh M C,V-\ <br /> SITE ADDRESS CI <br /> Street Number I Direction Street Name Citv Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) \'J <br /> 0 , <br /> 2 Z Z \ Street Number V 1 v`� Street Name <br /> CITY STATE ZIP <br /> �� cl eA GsZ�S <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (2.e ) �(o�Vl `�IGG <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR / CHECK if BILLING ADDRESS <br /> r3D(,I v Mel h <br /> BUSINESS NAME PHONE# EXT. <br /> c-Iran vin �d7Q sc> <br /> HOME or MAILING ADDRESS FAX# <br /> CITY �1 C\ STATE ZIP 2 <br /> 05 <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 /> , <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,ST and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 911, !Z07Ca <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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/sItle�ssessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availabPAXWE e�rl4Te time it is <br /> provided to me or my representative. f G ,Q �� <br /> EIV <br /> TYPE OF SERVICE REQUESTED: � J �( ` C�iV t/`""� <br /> COMMENTS: (� MAR 18 20 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: tnp EMPLOYEE M DATE: 3 I Y <br /> ASSIGNED TO: S` Y EMPLOYEE M DATE:AAAML <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount:Z Amount Paid `S Z Payment Date. 312 9 ZD Z� <br /> Payment Type Invoice# Check# Received By: <br /> V <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />