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i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 51ZOO 53 -7-� 3 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br />' <br /> FACILITY NAME <br /> SITE ADDRESS kJ q O g Q e �� ;� Oo\-\- OY <br /> reet Ste` Ck� <br /> StNumber Direction Street Name v 'v Code <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 /> ( 'LOCI LVI t- 5 55a, ` - 3�--3 Z <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# 'A EXT. <br /> HOME Or MAILING ADDRESS FAx# <br /> (Z69) to 15 y <br /> CITY STATE ZIP ' <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 /> 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 T 'TI?,and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATrE-:: 3 0 <br /> PROVER'IY/BIitiINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGFN"1'LJ <br /> if'APPIJCAN'Ti.s not the BILLING PARTY,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 DEPARTMEN'T 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: LkS-r- t pl t T— REC-IVE <br /> COMMENTS: MAR <br /> SAN JOAQUIN COUNIMA,?,ENVIRONMENTAL <br /> L0�$ <br /> HEALTH DE ARTME <br /> ACCEPTED BY: EMPLOYEE#: C <br /> UC--i t✓� i !�� <br /> ASSIGNED TO: Q A EMPLOYEE#: 1((-13(- DATE: Q PJ <br /> Date Service Completed (if already completed): SERVICE CODE /E:2_3 V <br /> Fee Amount: L Amount Paid (� , aQ Payment Date 31 pg <br /> Payment Type Invoice# Check# Z Received By: fGr <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />