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SAN JOAQUI.r UNTY ENVIRONMENTAL HEALT PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />nuc?3 6 <br />—r' fi r- -fest <br />SERVICE REQUEST # <br />- -Z <br />OWNER / OPERATOR , A T �\1 �� � �� <br />CHECK if BILLING ADDRESS <br />FACILITY NAME Elio (\J <br />HOME or MAILING ADDR_ESrS <br />SITE ADDRESS � 910 <br />Street Number <br />Direction <br />Street Name <br />Cit <br />Zi Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />s� r • t�nl 1 �� �bC� Street Number <br />Street Name <br />CITY STATE ZIP <br />PHONE#1 Exr. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #T ExT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR/ SERVICE REQUESTOR <br />REQUESTOR 6- /{n � : � F TAT <br />r ��i L� `��1�'Ar CHECK if BILLING ADDRESS/ <br />—r' fi r- -fest <br />1 t Ali <br />BUSINESS NAME <br />F, 2. 01ATN TATNf rTqc c� <br />ACCEPTED BY: M N r,11 94-1 <br />PHONE# ExT' <br />, 13-11-27>9® <br />HOME or MAILING ADDR_ESrS <br />DATE: <br />FAx# <br />CITY W � S' k--- 9A m T') <br />STATE C ZIP Cat -;;-6 <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 or <br />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 th t' e work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and F ws. <br />APPLICANT'S SIGNATURE: DATE: 12- — <br />PROPERTY / BUSINESS OWNER ❑ OPE TOR / MANAGER 67 OTHER AUTHORIZED AGENT ❑ <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 />TYPE OF SERVICE REQUESTED: tk&l- <br />COMMENTS: <br />ACCEPTED BY: M N r,11 94-1 <br />EMPLOYEE M <br />DATE: <br />ASSIGNED TO: ^ -e <br />a <br />EMPLOYEE #: /y.,1 <br />DATE: <br />Date Service Completed (if already Completed): <br />SERVICE CODE: 14A <br />t% <br />PIE: (� <br />Fee Amount: Zvi s <br />Amount Paid <br />` 5 C <br />Payment Date <br />j <br />Payment Type <br />Invoice # <br />Check # S—) �-3 <br />Received By:K; <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />