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W � SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />Ab SERVICE REQUEST <br />Typeusiness o roperty <br />BUSINESS NAME <br />CQ <br />FACILITY ID # <br />461 <br />HOME Or MAILING ADDRESS � % � <br />/ <br />SERVICE REQUEST # <br />SK C)0 5 100 S 1 <br />OWN / OPERATOR <br />CHECK If BILLING ADDRESS ❑ <br />FACILITY NAME <br />& LJ� <br />SITE ADDRESS ,�Z5 /9- <br />Street Number Direction <br />Stree ame <br />��� 9�5a n <br />Ci % Zlp Code <br />HOME or MAILING ADDRESS <br />of Different from Site Address) <br />' Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE. <br />( �' ,-1-f <br />T <br />/ <br />APIN # <br />1 �j -241- G?-- <br />LAND USE APPLICATION # <br />PHONE #2 <br />l 1 <br />EXT.BOS <br />DISTRICT,- <br />LOCATION CODE <br />C <br />1-11 CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR 4 <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />CQ <br />PHONE f Ext. <br />HOME Or MAILING ADDRESS � % � <br />/ <br />Fl�) J <br />TY STATE ZIP <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 app ca on and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ATE nd FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: % <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BimNGPARTY , 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. X'(V� ° <br />TYPE OF SERVICE REQUESTED: (�S 'T— ' U F (T- R f <br />COMMENTS: C EP <br />C;oJ UNvY <br />SAEN� R NME RTMENT <br />H�LTN pEPA <br />ACCEPTED BY: V EMPLOYEE #: �j Z DATE: cr 4- r0 <br />ASSIGNED TO: qi N 4—` [ EMPLOYEE #: s-6, 2 DATE: Q, �- 07 <br />Date Service Completed (if already Completed): SERVICE CODE: Gr I P I E: 21310g <br />Fee Amount: W <br />� D Amount Paid `H' o�-`� oz) Payment Date (o D -7 <br />Payment Type Invoice # Check # / z�,/ Received By: <br />EHD 48-02-025, FORM (Golden Rod) <br />REVISED 11/17/2003 <br />