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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/OPERATOR <br /> / n A. <br /> �/�/ / CHECK If BILLING ADDRESS <br /> ManFACILITY NAME l/C ^^1?e D�1./rl(/((`(�W r <br /> SITE ADDRESS /�'/ `- <br /> 144. <br /> Uo Street Number Direction tryc� Zip Code <br /> HOME Or MAILING DRESS (If Different f�o/mj pS/i�te Address) <br /> �' Vo �—WY 1 Street Number Street Name <br /> CITY STtT f M <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (mo) kw 706 `f <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTO <br /> Q / — A. ' ` ` CHECK If BILLING ADDRESS <br /> BUSINESS NAME ler So- r ( / PHOS#1 20q ) _ / Ear. <br /> HOME or MAILING ADDRESS / FAx# /V�L/T_ <br /> CITY Tr c. STATE c — ZIP 5377 <br /> BILLING ACKNOWLEDGEMENT: f, 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. ry n <br /> APPLICANT'S SIGNATURE: /MANAGER <br /> DATE: b L7� <br /> PROPERTY/BUSINESS OWNER O ERATOR/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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and a�t ee same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: t�V 1'LT L1 <br /> l� �c, �. �2S1µ,p h '�q0� ?AZO <br /> �TH�P ggFT Tq�N�Y <br /> �F'yT <br /> ACCEPTED BY: *� IAO S, EMPLOYEE#: Q 3/) DATE: �' � —r�,`� <br /> ASSIGNED TO: V V�L�J V v EMPLOYEE M Y �v} DATE: h� .V�v <br /> Date Service Completed (if already completed): SERVICE CODE: 1 I E: <br /> Fee Amount: l�2 _ Amount PailY �SHCl Payment Date <br /> Payment Type s Invoice# Check# Keceiv4d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />