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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5 nd a) I�el, ][5: R 008 1 a4a- <br /> OWNER/OPERATOR <br /> CHECK It <br /> 1 _ �, BILLING ADDRESS <br /> er <br /> FACILITY NAME <br /> SITE ADDRESS YIUI� C1'i <br /> Z�QIStreet Number Direction eet ame r City Zi Cotle <br /> HOME or MAILING ADDRESS (If Differentfrom Site Address) <br /> lQtyl ncA 11r Slreet Number Street Name <br /> CITY STAGE ZIP <br /> G ci/j <br /> PHONE#I EXT' APN# LAND USEAPPLICATION# <br /> ale ) 253- V700 uv) - 0 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQU STOR / <br /> irsCHECK If BILLING ADDRESS <br /> BUSINESNNAME Y✓L�V 10, C/ r/(tIJ l PH # SO2-- S2S� ExT <br /> HOME or MAILING ADDR SS v r FAX# <br /> CITY STAT ZIP 3 <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 /> 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 lawl. <br /> APPLICANT'S SIGNATURE: Ie�'�"'"� 1 '" DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT CgS,7t <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 an _same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 4.0 <br /> "yc~ ADFP4rrN-�y <br /> 4 Nt <br /> ACCEPTEDBY: Sh �.r.1 {� � EMPLOYEE DATE: <br /> ASSIGNED TO: Id a-Q EMPLOYEE#: DATE: o0 <br /> Date Service Completed (if already completed): SERVICE CODE: 5 1-- • P 1 E: ' .00 / <br /> Fee Amount: L�.S �Q Amount Pai a<–1 I)l Payment Date �Q <br /> t V <br /> Payment Type Invoice# Check# 3D Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />