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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Sc l ou 0 S 1 " tJ )p G 0 <br /> OWNER/OPERATOR a �n I- . <br /> � Vl �Oit J U I V1 Wu"L f`r ©' Ce C� r6toa -1(l ov, CHECK if BILLING ADDRESS <br /> FACILITY NAME eo` fu re� -�J c Bern 1 <br /> v J [ <br /> SITE ADDRESS 28ZC( j rams (,t,v-Id Drl•Ve S4ock4o,, g5,zofo <br /> Street Number FDir,,tion I Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> (Zdq) / <br /> PHONE#2 EXT, BOS DI TR CST LOCATION CODE <br /> ( ) I Gl <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 1 CHECK if BILLING ADDRESS O <br /> BUSINESS NAME Y✓- PHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> Z <br /> CITY -6L L„ �� STATE C4_ ZIP C�S ZO(p <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 Codec,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 7 110 <br /> PROPERTY/BUSINESS OWNER❑ OPE TOR/'MANA'GER OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not NG 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. p <br /> TYPE OF SERVICE REQUESTED: Ah-lir 41, <br /> COMMENTS: /tI <br /> N �W!A tNCO <br /> E9(ry�A'gRTT� � <br /> MFNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 2 Z I(G' <br /> ASSIGNED TO: C Z� , / EMPLOYEE#: Q DATE: `-7/Z 2-1(q <br /> Date Service Completed (if already completed)(:'' SERVICE CODE: + P/E: <br /> Fee Amount: G-L Amount Paid !S;� 0� Payment Date y3 <br /> Payment Type Invoice# 323 9�'� Check# �R�S6�S� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />