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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FA 0 o Z-I 01 3 9 R 00�2�Sq <br /> OWNER/OPERATOR <br /> CHECK It BILLING ADDRESS <br /> FACILRY NAME <br /> SITE ADDRESS (,.� r 0 p.1�-F C }� S� T-2,J S OCk-k,�r� °I52 :+ <br /> Street N✓umber Dlreotlon Street Name city Zip Code <br /> HLOME 0 NMAILING AzD„DRES/S' (�. ,IfnDiffe, rentyfrom Site A`ddres ) n t„ <br /> t�,/ l.LnlN 1X-�A,--Pv1 I1\^vl t/ Street Number UlL1`- treat Name <br /> ITY <br /> - TATE ZIP <br /> T17 #1 ' E'rT APN# LAND USE APPLICATION# <br /> !(�P©� ) 60 t <br /> PHONE#2 Ex . BOS DISTRICT LOCATION CODE <br /> (9ko) -7LoC U3-61 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> (REQUESTORI /1 I � ^^ <br /> O�ylrj( l�� vVr ` CHECK If BILLINGADDRE55 <br /> BUSINESS Nmmt n^ +PHONOE#-JEXT. <br /> HOM` EOrMAILINGADOR\ES FAx# 1 <br /> [ n A_ STATE ZIP <br /> l 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 idennfi n this form. <br /> I also certify that I have prepared this app/licat an at the w�k to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Slandard.,S'YAT an EDERAL I x S. <br /> APPLICANT'S SIGNATURE: / XTE;--r <br /> PROPERTY/BUSINESS OWNER❑ /O T 'MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPI/CANT' not the PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEAfSE 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 at the sat�.Eiple it Is <br /> provided to me or my representative. " I !".0" <br /> TYPE OF SERVICE REQUESTED: TwU �Gv ts�/L\' �fl�i , <br /> COMMENTS: S9N Og <br /> y�F �Fq RTT��7 <br /> 14 <br /> IV,n�q <br /> ACCEPTED BY: Y •1 Y Inn1s1�tY�V0 EMPLOYEE#: DATE: <br /> ASSIGNED TO: 1)M -- EMPLOYEE#: DATE: 1 �v <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: I�QOZ. <br /> Fee Amount: 1�2 D Amount Paid 152 , 00 Payment Date N12-E' <br /> Payment Type Invoice# Check# Received By <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11/17/2003 <br />