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~ SAN JOAQUIIGTY ENVIRONMENTAL HEALTH 40MENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> & (r72- <br /> Q� S�St1 <br /> OWNER/OPERATOR <br /> �t C� l �' ,�� � ��/;, '^ CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS �S�jl/• ��� lf• t��� �{� �l`��fil G ��� �p <br /> Street Nulmber Direction Street Name ( Cit Zi 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 r LOCATION? <br /> OCATION DE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> - . . . . . . <br /> BUSINESS NAME S•e�1� t C'e.. ����L.C")/) � S��Q(/I.,�S �� < PH-NP o'�l�•—�(�� 8 Ext. <br /> HOME or MAILING AD R SSFAX# <br /> CITY 75 6—i't 'Jo S^e- t STATE C,/1 ZIP 95--(/ <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 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Slandards,STATE and FEDERAL laws. <br /> APPLICANTS SIGNATIME: DATr: '/y. •� I O i ' <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIzED AGENT <br /> Y'APPLICANT is nol the BILLING PARTY,proof of authorization to sign is required 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: t <br /> ,,,I ,� C`��,"/l0✓1 . US � � S( f"/�-�rE <br /> COMMENTS: VIETtCe-c-r— ^V-••CK� Ut Ko �"C'eA ua-t)e-' `3p�,��C� <br /> V <br /> 'coin <br /> SAN JOAQUIN COUNTY <br /> NMENTAL <br /> ACCEPTED BY: C EMPLOYEE#: ,j 2-_ <br /> ASSIGNED TO: + EMPLOYEE#: k&-7 G DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: f Cs S/ P/E: Z L, <br /> Fee Amount: 0 Amount Paid — Payment Date <br /> Payment Type Invoice# Check#a Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />