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SAN JOAQUIN OUNTY ENVIRONMENTAL HEALTH SARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �1z6 Sty.�/o ✓� <br /> OWNER/OPERATOR <br /> � <br /> °/ CHECK if BILLING ADDRESS/ ' A �v,C • <br /> FACILITY NAME --� <br /> t rk J A <br /> SITE ADDRESS /s-r � N eZ Ck 77/1 G <br /> reet /`-p <br /> � OIJ 9j 3ro6 <br /> StNumber Direction Street Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) n� fr <br /> (" Street Number Street Name <br /> CITY / f L� V i t• TATE ZIP �+ L(Y/S <br /> PHONE#1 (* ExT• APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR n <br /> K t a e c,J ,� CHECK if BILLING ADDRESS <br /> � <br /> / EXT. <br /> BUSINESS NAME /'/�G�(.S C-- 'l Vl.0V"---S /`t PHONE <br /> # 3-D� <br /> HOME Or MAILING ADDRESS 14t 4tti.� t�'I!� 03 10 ) <br /> CITY 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 <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 JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and'FEDERAL laws. <br /> APPLICANT'S SIGNATURE: -��`4-11 DATE; WG/-® <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT s✓/!1"0 S cl <br /> 0 <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: �7- <br /> COMMENTS: C (J 9 - F/)�S� �` �P �] f CL L� l S <br /> ✓ > r <br /> �e\( C`" SPQ�s�r1 — lee-PC c-4. G t. y C t s to-e4 5-40—"'s <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />