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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> --A Oct +ADD zqs <br /> OWNER/ OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> CLQ Q NO t_ z7 A <br /> SITE ADDRESS '� � 1 ..r, P,-Iuv y 5'r[ A? -rO Coi P/ 5 21 cf <br /> 15 s- Street Number Direction Street Name city I ZIp Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) /04 I,r 7bb €Pi ;Pv�. Oe <br /> Streeeft Number Street Name <br /> CITY C STATE C ZIP <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> l 11 6 vi '-',16 G (0(0 O Z� i <br /> PHONE#2 Ex'T• BOS DISTRI `f LOCATION CODE <br /> ( } IP rV) 1i <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME _ <br /> PHONE# EXT, <br /> mel D l rVC / r'� �Ci flN rf? G E ��ZZ ( :Io 1S <br /> HOME or MAILING ADDRESS FAX# <br /> CITY r . STATE: ( ZIP t7 ✓7 r <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 /> 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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: `J„)4,' -/ �-z y(_ DATE: 220 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑� <br /> IfAPPLICANT is not the Brr.LIN_GPwRT:I 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 HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. p <br /> TYPE OF SERVICE REQUESTED: f%6 *Ov �AJIA-\� R�` I) <br /> COMMENTS: �-,, n� D� J'y��4 � �O <br /> f,J1A`I l fWl n"1 L! ED <br /> 20 <br /> fkw-, UW CrAL <br /> DU <br /> 4�ppR M HT <br /> ACCEPTED BY: `P <br /> rcW,n UC�, I EMPLOYEE#: DATE: `Z Z <br /> ASSIGNED TO: S YIR//fl A EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CooE: Oy PIE: <br /> Fee Amount: Z �} Amount Paid f C � J Payment Date 2 2 2 0 <br /> Payment Type Invoice# 1 Check# [ f Received By: <br /> EHD 48-02-025 / �Zl (� 1 Z ZGi 1 02. kc SR FORM{Golden Rod} <br /> REVISED 11/17/2003 5t✓l� 1 <br /> Pio"5zLJ r�d T( 1 W7-v 4, a f ewvv—sS t-w <br />