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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> _rA C d j v <br /> OWNER I OPERATOR <br /> A ?i U� ) _/e '1w CHECK If BILLING ADDRESS E] <br /> FACILITY NAME /' �/ LY L%/r-- <br /> A cis /A �2,?n% � a/asLr) <br /> SITE ADDRESS 3 3Vl {-f'C \„e`I � <br /> Slreel Number tlo Itreat Name i i�`t ' Zi Cotle <br /> HOME Or MAILING ADDRESS (If Different from.Site Address) <br /> 3d Ila / Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ell. APN# LAND USE APPLICATION# <br /> (90�) �a� al d <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (RoG ) Sef A76'/ <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR _ <br /> f� �?i U✓+'d CII /aYd().f/�S Ana <br /> f A��/@@� CHECK ItBILLING ADD�RtESsO <br /> BUSINESS NAME I ' lC��j l � nl Gt�.>Yti�d �GL�ISCIZL PHj) 4 q4LIxT <br /> HOME or MAILING ADDRESS AppRESS '1l — FAX##J <br /> CITY S /�/> L� STATE C11 zip 19, d (- <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 HEALTI-I DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this forst. <br /> 1 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: of DATE: 3- 3/ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> IfAPPLICANT 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 the same time it is <br /> provided to me or my representative. <br /> TYPE OF[SERVICE REQUESTED: 1�-rv,, P <br /> COMMENT W �� VV"VULVL'D_ P��ENEp <br /> y` \A _t 0 2 2070 <br /> S EI. ROryM COUNTY <br /> N 7Ai <br /> ACCEPTED BY: AA`VV xm ni3 EMPLOYEE M DATE: ENT <br /> ASSIGNED TO: _ l J EMPLOYEE M DATE: <br /> Date Service Com leted (if already completed): 1 . SERVICE CODE: PIE: <br /> Fee Amount: S2 Amount Paid Payment <br /> ent Date(6a2-0 O <br /> Payment TypeeA Invoice# Ce #— 000 36Received By: <br /> / <br /> EHD 48-02-025 t SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />