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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# RVICE REQUEST# <br /> 0 <br /> OWNER/OPERATO <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME _ <br /> 1 Y <br /> SIEADDRESS (,A) Aue- '����/ C153Gt <br /> Street Number Direction et Name CI Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Sheet Number Street Name <br /> CITY STATE LP <br /> PHONE#t EXT' APN# LAND USE APPLICATION# <br /> ( Zoy) 11Z- L4 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR A 1 �\ i <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> o.G� lCa 5 w kC+ Zn _�1'Z <br /> HOME Or MAILING ADDRESSp ) (Ax# ) <br /> CITY 1 L- C1 53 ,q <br /> � STATE LP <br /> BILLING ACK OWLEDGEMENT: 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 and FEDERAL laws. / <br /> PPLICANT'S SIGNATURE: /j( DATE: —lO—2O Z 0 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Titre <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. <br /> TYPE OF SERVICE REQUESTED: ID�OI ,� 11 "�'���� <br /> COMMENTS: �! Ilej <br /> s o <br /> ACCEPTED BY: llVI /A �,(_0 �' EMPLOYEE M V/ /�0�, / DATE: <br /> ASSIGNED TO: i""" """ EMPLOYEE M 1 7 l./ DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I P 1 E: W�3 <br /> Fee Amount: `{ Amount Paid /V.00 Payment Date Y l2 ZO <br /> Payment Type Invoice# Check# Received By; — <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />