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SAN JOAQUINVUNTY ENVIRONMENTAL HEALTH SARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER i OPERATOR CHECK if BILLING ADDRESS❑ <br /> Q VLIL St-00 A (7- 16 ET , mitt <br /> FACILITY NAME (� r O /Z k <br /> SITE ADDRESS W L 0 v f s E- A VEL M P•u t c a 95-33 6 <br /> I� ! 6 Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) e-ri\->it t S Rt S 7— <br /> e7l <br /> S 6 Street Number Street Name <br /> CITY O STATE � A ZIP <br /> PHONE#'I <br /> EXT. APN# LAND USE APPLICATION# <br /> (sI'D ) 6 r� � gr0 0 <br /> PHONE#2 / EXT. BOS DISTRICT LOCATION CODE <br /> ( 5-10 ) 6s� _ gss0 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ( C W 1 AY t WAC wA `T—Ot4 CHECK If BILLING ADDRESS <br /> A, PHONE# EXT. <br /> BUSINESS NAME i ,1 A L T-0 I-k (Z t ase-r2—t.4'(" , �i1�f C Ct t h2- <br /> HOME or MAILING ADDRESS Fax# <br /> CITY ,P-e,(L A-lM E Kt STATE p ZIP 6 <br /> . �-n <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 Codes,Standards, STATE and YIEDERAlaws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> 2 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT IP C 0 f.t-T fZ A-t'-ry rL <br /> If APPLICANT 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 the same time it is <br /> provided to me or my representative. <br /> r <br /> TYPE OF SERVICE REQUESTED: E.V l E W S(A E CT—,10 <br /> COMMENTS: I`I�� 7 c006 <br /> ENVIROIAMIN i HEA TH <br /> RERMMSERVICE <br /> 117 1,7 <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: / PIE: IFee Amount: 2--7y" Amount Paid 0 _ Dd Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />