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r V/1 E U1, <br /> ' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT //II <br /> SERVICE REQUEST <br /> sub <br /> Type of Business or Property FACILITY ID# # <br /> S-e�rV Ic>° S�&+1 o h b0d CO(a7 <br /> OWNER/OPERATOR <br /> i h TrA V 41a- <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME '--J-F--I t V) Tr-d Vt 6 10A ZA- <br /> SITE ADDRESS 15-0 ( S T,G k –Ib Nc Rd't i�1 f an Gr53(o{o <br /> Street Number I Direction �J Street Name city 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 /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> RiO/aQUE§ OR <br /> CHECK if BILLING ADORES <br /> - � D her-h /„ / 60,eo- 1•c( eXon <br /> 13 NEINAME PHONE# ExT. <br /> I(` Y64 I yah ( Corp 36 A L123-22 yS N3 <br /> HOME or MAILING ADDRESS FAX# <br /> 4 601UPA6iA 81 (3(06) q73 -az72- <br /> CITYJ e STATE 'I I 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 proje <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 JOAQ <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: l— D <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT 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 tti <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessme <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is a i4 at the same time i <br /> provided to me or my representative. QP• �”'wtV® <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: FEB <br /> ` cOVN-r( <br /> SAN dO P N eotA t MENv <br /> N�`�N pEPA <br /> ACCEPTED BY: EMPLOYEE#: DATE: Z� <br /> ASSIGNED TO: EMPLOYEE#: , t/J DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: rs' Amount Paid I*-)-T? 0 0 Payment Date a 3 V <br /> Payment Type ✓ Invoice# Check# 3F-7 Received By: <br /> Wl EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />