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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY IDII <br />FcsE Faad 2e51•s is o-�}� SERVr(I,,CE REQUEST #Q� <br />OWNERi OPERATOR v�lt"""I 11 <br />FACILITY NAME <br />SITE ADDRESS (,�6 C G' 1 <br />so- e SuirlY✓ J`' <br />HOME Or MAILING ADDRESS (If Different from SNO Address) <br />! o Szl <br />CITY <br />S f's c V. {•ah <br />PHONE#t En <br />tzo�) �3a -3243 <br />PNONE 42 Ext <br />Dcsc4l S <br />BUSINESS NAME <br />ASN <br />HOME or MAILING ADDRESS <br />10 <br />CITY <br /># — <br />y 01 1-10 D <br />CONTRACTOR/SERVICE <br />CHECK If BILLING ADDRESS 0 <br />Ty kc <br />STATE ZIP <br />LAND USE APPLICATION # <br />BOS Dis`ai(CT LOCATION CODE <br />CHECK If BILLING ADDRESS® <br />PHONE# <br />STATE n � ZIP <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: Q 41— , DATE: _ t Z S 1 y <br />PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIzED AGENT <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Titie <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 timij L'sprovided to me or my representative. J A <br />TYPE OF SERVICE REQUESTED:tv (�l,{/j�j!/ <br />�(!✓� <br />•, <br />COMMENTS: <br />[� <br />CC <br />0 <br />J <br />Hc�C'V(.iRON/N c <br />ACCEPTED BY'i ✓ru ei L -a <br />EMPLOYEE#: <br />DATE: 1Z e3 `7 <br />ASSIGNED TO:Ate Va d <br />EMPLOYEE#: <br />DATE: IZ S <br />Date Service Completed (if already completed): <br />SERVICECODE: 6o <br />( P1 0 <br />Fee Amount: I SZ ____ <br />Amount Pai <br />�S� <br />Payment Date <br />/ S <br />Payment Type . sem_ <br />Invoice # <br />Check # 102_12112_b <br />Reeei ed By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />'I kilf <br />O <br />13019 <br />>NNry <br />4 <br />ENT <br />