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SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# �nSERVICE REQUEST# <br /> OWNER/OPERATOR <br /> 1 1 M f 1,/(� V CHECK if BILLING ADDRESS O <br /> FACILITY NAME �J 1 C <br /> 'ti'l,�l 1 fi '- f <br /> SITE ADDRESS 2`I V V � j—,Ll Y 61 fl GI Yv f�` S�1J C�-,VS Z CC' <br /> Street Number Direction J StreetName Ci zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) / r! f,, S, 1 Y1 C\co, c <br /> lV S[treeltYNumber Street Name <br /> CITY SSTATE ^c ZIP cI S 2 1 c-) <br /> PHONE#1 Exr• APN# LAND USE APPLICATION# <br /> (51a 22Qj -5�5�I <br /> PHONE#2 EZT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Ck C eML L o}�C Y)z v CHECK if BILLING ADDRESS <br /> BUSINESS NAME t V PHONE# ExT. <br /> Sl212I5 ti <br /> HOME or MAILING ADDRESS / [\� FAX# <br /> LVl.Y <br /> ITY Ci STATE C� Zip C G J-- <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 ENVIRONMENTAi. 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'SSIGNATURE: Lo m�1yAr- Z of Y12y DATE: D S l O Lf 120, <br /> PROPERTY(BUSINES OWNERP d OPERATOR/MANAGER ❑ OTHER AUTnORIZED AGENT❑ <br /> IfAPPLICA.T 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 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 I ^,s�me time. it is <br /> provided to me or my representative, Y <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> SAN MAY 04 ZD20 <br /> ENA <br /> OQU/N <br /> HEQCT Ro <br /> C)gRTM L <br /> Z/vr <br /> ACCEPTED BY: EMPLOYEE M DATE: 9.q.ILC) <br /> ASSIGNED TO: EMPLOYEE#: DATE: � <br /> Date Service Completed (if already completed): SERVICE CODE: (� !I E: 47 <br /> Fee Amount: 1 ' Amount Pai f b(� Payment Date <br /> i <br /> Payment Type S� Invoice# Check# �(�8 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />