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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESSL-AV` VwV/ C� S�c,cI�CN �S ZL�3 <br /> � Street Number Direction C �V✓\0� T ee Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) q0.0 N <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (g 60 S 1 — <81,3- <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> V\'„` CHECK If BILLING ADDRESS <br /> BUSINESS NAME V PHONE# EXT. <br /> P��eSS�o�cti e 5 �"A V\-� c C 5 <br /> HOME or MAILING ADDRESS FAX# <br /> CA C80 <br /> CITY C STATE r� zip 0 - l 1 <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,STATE <br /> /and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: d f—C ,�/ DATE: l t G 1 c <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER L�1 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 proper` ]& ted at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environment ip <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at Ips I <br /> provided to me or my representative. —~`I yE <br /> TYPE OF SERVICE REQUESTED: �Q�n } �t�,h< �yr 1SA'A 1vl O <br /> COMMENTS: C - �Q�Al rw,L.. r <br /> ��cnNS 2� o� �nPtn\-�� c �- , � �v c U eY c t ME �Y� 15 eFc vt� <br /> N A..P�,q9R�NTAt <br /> �O n(-O�pe7 )v v'%'` SQOrAS C�.tec��S. ��. >�ec '� m �v5A �q- Cuw•y) 1� 1 t 4T <br /> y Oz-1 *- VZ43 - 6 Ise nvv' �o(- �',4 W✓ "'k e F-o&V <br /> ACCEPTED BY: EMPLOYEE#: / Y ) DATE: ' 1012-02t-) <br /> ASSIGNED TO: 06ir <br /> I / EMPLOYEE#: (o/ DATE. ' ,O <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: &( - <br /> Fee Amount: Amount Paid I r r1 Payment Date <br /> Payment Type Invoice# 6 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />