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CAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> f w 002, 5-106 5R ®©ga-900 <br /> OWNER/OPERATOR <br /> /. CHECK If BILLING ADDRE55� <br /> AL d <br /> V i tJ/`Q / <br /> FACILITY NAME <br /> LStre_CeJt Number Dlrect /w``^1'�_��/ qq 5FJ///1G911�JQL / <br /> SITE ADDRESS 47A . /e /?(/ <br /> Io Cit � <br /> 9� <br /> Code <br /> HOME or MAILING ADD SS (If Different from S' Ad ress) <br /> �� /v� Street Number Street Name <br /> CITYSc� ei� STATE ZIP ZD <br /> PHONE#1 EXT. APN# LANDUSEAPPLICATION# <br /> 210 <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR '� <br /> / j,"'� / Z tjI�ed I CHECK If BILLING ADDRESS <br /> BUSINESS NAME •—�'��l / UA1, �O/ PHONE III EXT. <br /> L C� <br /> HOME Or MAILING ADDRESS �� ) FAx# <br /> M <br /> CITY rCCi< `�'+� STATE C�4 ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> PPLICANT'S SIGNATURE: DATE: �/ Z zy <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> IfAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. w <br /> TYPE OF SERVICE REQUESTED: 'r"U O� v�"I CL-C- tv'' PCZ'I l il AI' <br /> COMMENTS: %, <br /> OCA - D <br /> SAN✓O 202 <br /> H fN�RO M OOuN <br /> STH pEp NTA( <br /> ACCEPTED BY: t�((T EMPLOYEE#: DATE: L'o TtA <br /> ASSIGNED TO: elC ML (2-r--Zi EMPLOYEE#: DATE: l U - '2-9 -1.0 <br /> Date Service Completed (if already completed): SERVICE CODE: V 1 PIE: 16 O J <br /> Fee Amount: 2 L,� Amount Paid Payment Date D-2-112-0 <br /> Payment Type O /��/yyj�In{v�oice# /, /� Check# Received By: <br /> EHD 48-02-025 opy#_ �� �� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 (� 1 S <br />