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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> YJ <br /> OWNER/OPERATOR �� <br /> I1,� ��� CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS �-.5 7L, <br /> Street Number Direction Street Name 1 ( C' Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Stmet Name <br /> CITY STATE ZIP <br /> PHONE#1 ErT• APN# LAND USE APPLICATION# <br /> (530) 4 01 - Ll 7 K� <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> fC)vie., ' L)I f CHECK If BILLING ADDRESS <br /> BUSINESS NAME r---� W 1 PHONE# E'R• <br /> 1 0 IitVt I� r w VIS4-r <br /> HOME Or MAILING ADDRSS FAX# <br /> 2 k%�' cl e— <br /> ( ) <br /> CITY V C <br /> S Ck STATE ZIP Y <br /> BILLING ACKNOWLEDGEM ,NT: I, the undersigned property or business owner, operator or authorized /agent of same. <br /> acknowledge that all site and/or project speck ENVIRONMENTAL HEALTH DEPARI7,4ENT 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, ST FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 7 Z 7 O ZO <br /> PROPERTY/BusL-iESs ONvN-EROPERATOR/NLILNAGER ❑ OTHER AurrHoRizED AGE-NT <br /> If APPLICANT is not the BILLLNG 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 arty and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR"C.MENT as soon as it is available and at the same time it is <br /> provided to me or m}, representative. e <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> CE�V� 7- <br /> SA N MAY o 6 20?0 <br /> J0A <br /> NF,q tN T11 pNM�CpUNT <br /> ACCEPTED BY: /L /'K EMPLOYEE#: DATE: TILJENT <br /> ASSIGNED TO: i VA EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: 16,02— <br /> Fee Amount: /j�? ID Amount Pa" /52 0 Payment Date .S G <br /> Payment Type /'-so— Invoice# Check# D ZSR Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />