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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER i OPERATOR �J <br /> JV 1} � &v N Z�L£Z CHECK If BILLING ADDRESS 1�1 <br /> FACILITY NAME (� �t <br /> >✓� � ZCI- <br /> ��Cfl (Z-€SZ•4vf�rtN <br /> SITE ADDRESS ul P i N C— S 7fZ � L o F• I SZ Lf I) <br /> l 12• Street Number Direc ion treet Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2dq ) (o to Z. `lad Lf <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> o l2 2 ar <br /> BUSINESS NAME PHONE# EXT. <br /> E A (2 C IPt-I `rft--(v rz—e Zo &( Y6 7 <br /> HOME or MAILING ADDRESS FAX# <br /> 18S S Vt A S At AVE ( I <br /> CITY -�—pOCK?b STATE �Q zip p�Z� <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 forth. <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 /> APPLICANT'S SIGNATURE: . �, �,,�� DATE: ' 2 2 L o Z o <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> /f 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 available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: C�V�D <br /> AN <br /> SAN J0 ?020 <br /> N FNV/RO Ull y <br /> TH p Pq ENTA N�' <br /> ACCEPTED BY: � �� CJ <br /> EMPLOYEE#: DATE: ' 2 <br /> i <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Z P/E: Iwo/ <br /> Fee Amount: LW LAW Amount Paid' S , Ub Payment Date <br /> Payment Type Invoice# Check# Received By: 77/7,/ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />