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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTInEPARTMENT <br /> SERVICE REQUEST • <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 52oo( ) I q l S <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> —AAM A-rig06f4J oro- 4Z <br /> FACILITY NAME �TST Zx P2f5S p, <br /> SITE ADDRESS ` �don1 CTK <br /> 1 `3O Street Number Direction SD (� T V Streel Namet city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 3 7 t Z Street Number Street Name <br /> CITY STATE ZIP <br /> ` Cor-v-corj a eI-�,2kq <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (7D i) 6)191 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME t PHONE# EXT. <br /> HOME or MAILING ADDRESS <br /> CITY STATE ZIP <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 projector <br /> 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: / Y� DATE: Z (� ISA I J <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> LfAPPL/CANT is)lot 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, geoteclmical data and/or environmentaUsite 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: / Q <br /> COMMENTS: RECEIVE <br /> FEB - a Nil <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: 7 DATE: Y / <br /> ASSIGNED TO: EMPLOYEE#: / DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 6G 1 PIE: 63 <br /> Fee Amount: I—2. Amount Paid �22— Payment Date <br /> Payment Type ✓ Invoice# Check# Received By: �r <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />