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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C C� c V C A i �-'i q Vb 3 R00 &c2 4 7 <br /> OWNER OPERATOR 1� q <br /> n V` \ CHECK if BILLING ADDRESS❑ <br /> k --Y — v r <br /> FACILITY NAME <br /> SITE ADDRESS <br /> { �a ` r L,c 6S2L10 <br /> Street Number Directlon `V\ ✓ C eel N me CI ZiCode <br /> HOME or MAILING ADDRESS ((if Different from Site Address) .3 <br /> 1 Y Street Number �C'm' <br /> 0,--\ Street Name J�� 0) <br /> CITY _ STATE W ZIP S 2-L-1 0 <br /> C? J <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (�O�) 7 \ S S S <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ()L` Ry 1 F 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / <br /> A gam a CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> H ' ) 'A -,::,z Z <br /> CITY L v S TE ZIP Q, ZL' <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. <br /> APPLICANT'S SIGNATURE: ; L`�_ C, y VC--'C-'C O.' C\C'\ DATE: I 12-C <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER d 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 avasame time it is <br /> provided to me or my representative. �� � <br /> TYPE OF SERVICE REQUESTED: Old an S u, ItoWnAUGCOMMENTS: A <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> cAgv Of oWfi(rSh-k <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Vt. <br /> v f�� ,� EMPLOYEE M DATE: �J <br /> ASSIGNED TO: V EMPLOYEE M DATE: I' 12,6f <br /> Date Service Completed (if already completed): SERVICE CODE: ! / ,P/E: <br /> Fee Amount: I Z Amount Paid Payment Date /� 11 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />