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SAN JOAQUIPOUNTY ENVIRONMENTAL HEALTH APARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> L ko Fl LL FA -4:5 ls)evo &Z-6 Z% <br /> OWNER/OPERATOR <br /> F6)R', st /I//'ry✓�POR CHECK If BILLING ADDRESS <br /> Teb <br /> FACILITY NAME -AOR w j)V (if. �`� <br /> SITE ADDRESS t ! ` / S� � -!LVA) A�� M.r0�1 CT , lq.�7-33 <br /> Number Direction "t [ ' Street Name /INIZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) D <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN#90/�t P60 C7� LAND USE APPLICATION# <br /> ( ) xo/o6r✓o ��c6'oo7; ENVIRONMENTHFA <br /> F+ <br /> PHONE#2 EXT. BOS DISTRICT Vi�ICE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ry`-/ We /*i-bb0X CHECK if BILLING ADDRESS <br /> t X71 AVL/ /\ <br /> BUSINESS NAME F> d -5 PCEXT. <br /> p # � Q -7 77 <br /> HOME or MAILING ADDRESS FAX# <br /> I © ( ) <br /> rCITY1>1'10rM0'6a? <br /> STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized6 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: DATE: �� �f Q <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ O ER AUTHORIZED AGENT 9 <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. y <br /> TYPE OF SERVICE REQUESTED: � � /�?I ►V�T��l�� ��q O . <br /> COMMENTS: <br /> MAY 2 6 <br /> sa,^� onau v co!_�H7Y <br /> ENV"I�O"d t�'ENTAL <br /> HEALTH DEPART Ela. <br /> ACCEPTED BY: - EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE C DE P/E: <br /> Fee Amount: C-o Amount Paid Payment Date 5 I 2(0 <br /> Payment Type ✓ Invoice# Check# Lt L- S S b Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />