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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property — FACILITY ID# SERVICE REQUEST# <br /> '��0" <br /> OWNER/OPERATO <br /> Y/ �a CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> � S t <br /> SSI�IT��E((ADDRESS � CLp 3� L©� � � QS�C.ra <br /> O�r'iD1 Street Number Direction Street Nama -- City Zip Code <br /> HMAILING ADDRESS (If Different from Site Address nt' f-1-k— 1QD <br /> Ho <br /> Number 1 �eG � Street Cl STATE C ZIP <br /> PC� <br /> ONE#1 Ea, APN# LAND USE APPLICATION# y <br /> 1 �yga -esa <br /> PHONE#2 Ea. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> � CHECK If BILLING ADDRESS <br /> BUSINESS NAMEtiPH NE9 Ezr. <br /> o 's � ��;�; oma ga- osa� <br /> OME Or MAILING DDRESS FAX# <br /> C �0C) ( ) <br /> CITY oc -�VSTATE C'6, ZIP G'C'1 Fl <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: I1511PW � ti 10 ! M 0 DATE: 1 <br /> ROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tire <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. t <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> Mov p <br /> B/yJOA <br /> qQU/N <br /> V HB 9ClHUFpg47 tN7y <br /> F <br /> ACCEPTED BY: rs EMPLOYEE#: DATE: I 5 <br /> ASSIGNED TO: vl EMPLOYEE#: I v DATE: I <br /> Date Service Completed (if already completed): SERVICE CODE: W1 P/E: �2 <br /> Fee Amoun . �� U Amount Pal (S� �(� Payment Dateik <br /> Payment Type Invoice# Check# !` ! Recelved By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11/17/2003 <br />