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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> rlul�il-A Ck"A- Oo<gt-( -7 SS <br /> OWNER/OPERATOR \ <br /> CHECK If BILLING ADDRESS❑ <br /> \ i 1 <br /> FACILITY NAME <br /> l u <br /> SITEADDRESS L l 1 e � C <br /> I; 1 o use Shock n� s� o} <br /> Street Number Dlrection root Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> V:) r p � CNECK if BILLING ADDRESS <br /> BUSINESS NAME PHO # EKT <br /> �, tA\ At u G er 9O -2 SP3 s TC) <br /> HOME or MAILING ADDRESS FAx# <br /> Z(oZ YiG f(1 I ) <br /> CIN 'Pt STATE ZIP <ZZ <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 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Coder,Standards ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: r1� 1t <-y f'f OVATE., G • � � a�— <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/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 /> inf nrnation t0 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. p <br /> TYPE OF SERVICE REQUESTED: C a —nei( — t\j VU a. J NT <br /> COMMENTS: <br /> JAN? 0 <br /> 1 <br /> %V°Aou! ?O?? <br /> yDEa �IY <br /> ACCEPTED BY: yLf,(�C S EMPLOYEE#: DATE: ,w —22 <br /> ASSIGNED TO: at d! r1 EMPLOYEE#: DATE: Z__ <br /> Date Service Completed (if already completed): SERVICE CODE: —7 PIE: D <br /> Fee Amount: Amount Paid-'5DlJ U Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />