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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 03�, smol:35%36� <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME Wo I n ^'/1 0610 <br /> SITE�DD12ESS <br /> (! k ��� <br /> v Street Number Di�tion W 1 Street Name Ci #' Zi o e <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 /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ` I. � O� <br /> V CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHON # 4 EXT' <br /> H r MAILING ADD ESS N �✓� ��_ 36 (ZM ) 3(A- I c J 1 z <br /> CITY STATE ZIP ��00 <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 ENVIRONMENTAt. 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 /> 1 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 and FEDERAL laws. O� <br /> APPLICANT'S SIGNATURE: / DA'L'E: I - I �g� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 0TIIERAirmoRizF.DACN:N'1'&— OpriCk 1AANF�f( <br /> if APpctCANi'is not the BILLING PART 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/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTFI 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: ED <br /> COMMENTS: NOB 7 SEP <br /> ocl U <br /> SAAaapauMG 1-914MOI NIE[� f tiEAL.TH <br /> 4iEALTHDEPARTMENT PERMIT,/SERVICES <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: air 1 <br /> P/E: <br /> Fee Amount: Amount Paid ' S Payment Date `b <br /> Payment Type ✓. S Invoice# Check# 122q , an9Cli, Received By: <br /> 2 3 SR FORM(Golden Rod) <br /> EHD 48-02-025 J <br /> REVISED 11/17/2003 <br />