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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> i SERVICE REQUEST i <br /> Type of Business or Property. FACILITY ID# SERVICE REQUEST# <br /> 6 As STS Tl o pbU v54 <br /> OWNER/OPERATOR <br /> / r Zts-rri/ CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> L V IMc J <br /> SITE ADDRESS �Y6 I <br /> StNumber Direction <br /> reet Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> V d /,SO 31 v Street Number Street Name <br /> CITY STATE Lcr ZIP <br /> PHONE1 E.T. APN# LAND USE APPLICATION# <br /> 51 ("pup I <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> 33 7 <br /> HOME or MAILING ADDRESS FAX# <br /> 53 S 6L), c Ccs' (2e5r6�T - <br /> S:/-vC � J � C <br /> ] 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar TATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: j / DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑�it,(JLC��-CX��� �� <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. A <br /> TYPE OF SERVICE REQUESTED: C�I�/ T <br /> COMMENTS: <br /> sq C 15 <br /> NJO ?005 <br /> ADUI <br /> H FNVigo NODS <br /> �T N D p�R MFNT <br /> ACCEPTED BY: EMPLOYEE#: 30`') DATE: I Z IS eis <br /> ASSIGNED TO: kv,` EMPLOYEE#: q(�-3 DATE: /2 /S a� <br /> Date Service Completed (ifalready completed): SERVICE CODE: f t P 1 E: C <br /> Fee Amount: �!' Amount Paid 'a✓l Paymlent Ja Date �u s bS <br /> Payment Type Invoice# Check# 10 '� Received By: N <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />