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SAN JOAQUI*UNTY ENVIRONMENTAL HEALTH #ARTMENT <br /> • SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> /p,pSt/1 ,rF/y1 U�P CHECK If BILLING ADDRESS E] <br /> FACILITY NAME 'n �'/1`" ,V^l l <br /> 3� <br /> SITE ADDRESS I�ctet`-(�`L� U-e- 5tvckc� 9 Sao? <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 1 Street Number Street Name <br /> CITY rA STATE C4- <br /> ZIP Y^q!�aq <br /> PHONE#1 (J`• ExT• APN# LAND USE APPLICATION# <br /> 0 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> �\ati'n' 0,� CHECK If BILLJNG.ADDRESS� <br /> L��' Y w <br /> BUSINESS NAME PHONE# E.T. <br /> � -� <br /> HOME Or MAILING ADDRESS (Py- o /, ^��Vt -Au-k-, F # Qk <br /> CITY S STATE 6+ ZIP p��/•� <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 /> COUN"fY Ordinance(,odes,Simulards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: I r_f <br /> �oc •tr-,1, .�, pec.-f.trl.�'-�L� DA'rr• <br /> PROPERTY/BUSINESS OWN Lit❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTio "./16[ ;io cr ca <br /> If,,1PPL1C'ANT is/701 the BILLING PARTP,progf of authorization to sign is required It 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 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: 1A k <br /> f( "��,( <br /> COMMENTS: W� �r ,V lCT1 'y <br /> G 1 L �? C;O2000 <br /> V S UNv,. <br /> SPN 30A.OUtMlas TAI- <br /> vex <br /> �H DEPARTME� <br /> ACCEPTED BY: EMPLOYEE#: 2 K� DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: S J Amount Paid "� l s , Payment Date 6kl Lk I a 8 <br /> Payment Type �/ Invoice# Check# Z Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />