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SAN JOAQUTAOUNTY ENVIRONMENTAL HEALTH AARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> w12►' <br /> OWNER/OPERATO <br /> O iy�.�L�IP� CHECK If BILLING ADDRESS <br /> oc <br /> FACILITY NAME / �, ,n uKhkias .11 <br /> (� <br /> SITE ADDRESS .324 2- S at tarc.0 S-Iyen� S—trZ ,�/) !5?,(� <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) Q—+1 1 ( I W—(VV p(Zt V.— <br /> Street Number 7 Street Name <br /> CITYS+Oct*vl S ATE ZIP r1S"Z <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# , <br /> (3(0) 150-Lta l(e l 0 2.0? <br /> - <br /> 14b <br /> el�T l 1 BOS DISTRICT <br /> LOCATION CODE <br /> c I �yq,. 3k9 ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESSW <br /> 7-(!7H -7EeAmii— <br /> BUSINESS NAME ' PHONE# ExT. <br /> l i,✓r s- Jaz <br /> HOME or MAILING ADDRESS . FAX# <br /> CITY t , ^- STATE ZIP C/Z6L/ <br /> / / .A <br /> BILLING ACKNO EDGEMENT: 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 a FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ,� '-4 —� DATE: �(`" ^� 7 <br /> PROPERTY/BUSINESS OWNER❑ OP `TOR/MANAGER ❑ OTHER AUTHORIZED AGENy2 <br /> If APPLICANT is not the BILLING PARTY,proof Of authorization t0 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_al h ,-,ine time it is <br /> provided to me or my representative. �P•Y Q <br /> TYPE OF SERVICE REQUESTED: nnRl <br /> COMMENTS: V/S/0' 14/ 0'0dr'K.4')V.-I <br /> 7 .'V hrr- �?,?3 mS�r PC t' -3 'P-6 N�o,�N <br /> �pP E1.1�PL S <br /> 91710-7 ' .57/14-S � G'✓ s� w C� ���' �6P ��AP�MEN <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: ZaJ �,� ^ 0 ount Paid gq Lf CcPayment Date 7 J <br /> Payment Type ✓ Invo ce# Check# F11 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />