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S a <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �Looq� '?V �0 oos3i)-'I-t <br /> OWNER/OPERATOR M ey cedes <br /> edes q-,I, A t _ - r _ FCK if BILLING ADDRESS❑ <br /> FACILITY NAME �y� <br /> SITE ADDRESS 5iw, b/� r- {i[!�trelel Numbe► Direction CAnStreet Name CIt I`"I il! I Zi Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) 2C ?]� <br /> Street Number Street Name <br /> CITY [�� , � STATE � ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2 ) U�3- 3S�9�+ <br /> PHONE#2 EXT, BIDS DISTRICT LOCATION CODE <br /> t ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ��C� S GA'I `_ _ 1_ <br /> liC V� T`LC�t'1it CHECK if BILLING ADDRESS <br /> BUSINESS NAME �� �� t � PHONE# n, EXT' <br /> 1 !� <br /> HOME or MAILING ADDRESS /� -7� �J;n� + j.Q SAX# <br /> CITY STATE (1.. ZIP <br /> BILLING ACKNOWLEDGEMENT: 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. Z Q <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPE -MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to 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 availablet the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Cil <br /> COMMENTS:�rn 98 ,202g 8 ,20ZQ <br /> N���EP�NTaC� <br /> rM�NT <br /> ACCEPTED BY: 1 r/1 �'frJ) EMPLOYEE#: q 0 DATE: <br /> ASSIGNED TO: Lam` EMPLOYEE#: v DATE: V <br /> Date Service Completed (if already completed): SERVICE CODE: P i F: <br /> Fee Amount: Amount Paid a Payment Date 12-12 6120 <br /> Payment Type Invoice# Check# f Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> r' <br />