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�-" SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property� / FACILITY ID# SERVICE REQUEST 0�7cd1e�� 0/2 /aces <br /> OWNER/OPERATOR nr) / <br /> A O7SO Jam/ CHECK If BILLING ADDRESS <br /> FACILITY NAME -V-Z <br /> 7�a ras ui`l�e <br /> SITE ADDRESS /,;,/I;x <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or qMAILING ADDRESS (If Different from Site Address) <br /> /3R LJC/C/- �2` Street Number Street Name <br /> CIN 6-ZeCA/0,17 CAT�'E ZIP <br /> PHONE 91 EXT. APN# LAND USE APPLICATION# <br /> $Z9 <br /> PAHHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> c 4 EXT. <br /> BUSINESS NAME �.- PHONE# <br /> HOME or MAILING ADDRESS a FAX# <br /> CITY C��C - $TATEdA ZIP Cj�2O�r- <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 Coder,Standards, STATE and FE ` <br /> APPLICANT'S SIGNATURE: 11�TOM DATE: // zpz <br /> PROPERTY/BUSINESS OWNER El OPERATOR/?4 NAGEq OTHER AUTHORIZED AGENT <br /> IfAPPL7CANT 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 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; <br /> COMMENTS: I`{i, '6b( <br /> AYINEIVT <br /> RECEIVED <br /> *V 0 21020 <br /> I /y <br /> SAN JOAQUIN <br /> ACCEPTED BY: I q t%rI EMPLOYEE#: t/t NEA P <br /> ASSIGNED TO: l `r t m EMPLOYEE#: _ l DATE: <br /> Date Service Completed (if already completed): SERVICECODE: 6 Do) PI : 1l . �3U <br /> Fee Amount: 2 Amount Paid f a Payment DateMR I 2 �loV <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 n SR FORM(Golden Rod) <br /> REVISED 11/17/2003 �1� Ol,�l7 <br />