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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST (�-* VVA <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> J sa-ot�- <br /> 5 NER I OPERATOR_ CHECK if BILLING ADDRESS❑ <br /> FACIL'LIITYNAME FWD <br /> (7-'E 7or <br /> $ITE ADDRESS) l o g I / V61 + 01 q 5LA <br /> Street Number I Direction I Street Name Cit Zip Code <br /> _-HO—ME Or lV1AILING ADDRESS (If Different frPm Site Address) �7 R�, -� <br /> 3 eel Number Street Name J <br /> ( CTI p\ r� J% STATE ZIP of rJ3 <br /> PHONE#]' IU t y-Elm rv, APN# LAND USE APPLICATION# "I <br /> 4(5j ) <br /> 321— 3`[`i <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEST? -n ,q-�V n �I �'\ <br /> FA " /1 r �/ !`tel.°✓`-' CHECK if BILLING ADDRESS <br /> BUSMESS NAME 6o�D I LA t✓(.RA S y-SS� �b� PHONE'51 '321 _ /EZT. <br /> 'HOME or MAILING ADDRESS!']' FAX# 1 <br /> A„4,Tun >r ( ) <br /> �CITY'f A r ola.)o+W Af'i a— e46 STATE ZIP GJ'-'53-1 I <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 Codec,Standards, STATE d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 17 DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ <br /> //MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PART}'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 at the Same time it Is <br /> provided to me or my representative. `1 <br /> TYPE OF SERVICE REQUESTED: —t-QQ VQ1n1C�.e IL(\%y&k 6\Ai P <br /> COMMENTS: CleCEIVIV bw,V4 � s� �P <br /> 2�v y ? ?020 <br /> eo <br /> SAN JDA <br /> ENVI QVIN CO <br /> IV <br /> HEALTH p NMEN-AAL <br /> ACCEPTED BY: `A A EMPLOYEE#: DATE: <br /> ASSIGNEDTO: 1I/�'I/WAVIVIO/V S EMPLOYEE#: DATE: v <br /> Date Service Completed (if already Completed): SERVICE CODE: Mo P/E: 2 <br /> Fee Amount: C'j-Z� Amount Paid Payment Date I I Imo„(2-bJ <br /> Payment Type 0. Invoice# 4T C t-W VY% Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11/17/2003 / <br />