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i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 50kct WU ecz SSC v S o <br /> OWNER/OPERATOR <br /> --�� CHECK if BILLING ADDRESS <br /> FACILITY ME <br /> SITE ADDRESSto v1 CLIC <br /> O t v Street Number i5 ion 4L)5 <br /> r , meC~ice- .' Zi ode <br /> HOME or M]AIILING ADDRESS (If Different from Site Address)✓{ ' e, l/��j" {� / <br /> 6- Street Number �'" 44.-.t N`amXeJ <br /> CITY l/T-() �u� STATE ZIP /3 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 00 ) L4W-p -11bicta, as OW10600 <br /> PHONE#2T• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> R.EQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAMEAlt. <br /> PHONE# ExT <br /> t <br /> d e-/&&- 5-/ <br /> HOME or MAILING ADDRESS FAX# <br /> CITY f()/'I/I/ p/�41 STATE ZIP /t J <br /> BILLING 11ACC 1NO 1W�'(LEEDGGEMENT: 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,STATEFEDERA WS. <br /> jand APPLICANT'S SIGNATURE: ��(--- DATE: �n l�n�t�° �� J�/� /^/' <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER 9 OTHER AUTHORIZED AGENT❑ ��PJ�may( I�(dii� a <br /> If APPLICANT is not 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 jt4Z- ►me time it is <br /> provided to me or my representative. M �`� <br /> TYPE OF SERVICE REQUESTED: U [ D v ,}_S 7`-C /-)e-A-,,,/ <br /> COMMENTS: / <br /> -7 ( �� j_-r` . APR� GDV�1� <br /> � <br /> 111 OP t N,lA- <br /> SP �MEtSC <br /> N <br /> ACCEPTED BY: C / �- C /�o EMPLOYEE#: �3 Z � DATE: �! /�7 <br /> ASSIGNED TO: A C EMPLOYEE#: 4f 4,- 3 DATE: 41241'0-7/ 2410-7 <br /> Date Service Completed (if already completed): SERVICE CODE: S'2 2 PIE: <br /> p 2 <br /> Fee Amount: n o `rte, Amount Paid C)D 0 Payment Date <br /> Payment Type Invoice# Check# a 93 0 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />