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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property (� FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR, j <br /> I QYI -`� Oy t- if 11 ti CHECKBILLING ADDRESS <br /> FACILITY NAME t -� <br /> T <br /> SITE ADDRESS 900 <br /> ^ , ' <br /> street Number Directlo I et ame Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) J �ZPr kesl NO <br /> Street Number treet Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (20") ) t 1207 /3 6 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> l J <br /> CbNTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> —r- _ PHONE# ExT. <br /> BUSINESS NAME 1 <br /> IN �E � ie�l�lJ C' 2^�7 ZG)7 J3 Y, (.. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY - STATE ZIP <br /> '1-rGt ' v CIS- Cl 53.7 (o <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 Rad VEDERAL laws. <br /> APPLICANT'S SIGNATURE: , , DATE: 6111-11 A0 Z0 <br /> PROPERTY/BUSINESS OVINE4 O ORATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> IfAPPLICANTis not the BILL/NG PARTY proof of authorization to sign is required Tate <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 thp"time it is <br /> provided to me or my representative. JJ �� f��y��/�1�I` <br /> TYPE OF SERVICE REQUESTED: &(j L(,)tl•St/C'Q t/�I / OVZ <br /> COMMENTS:: / 6 <br /> 0wi t$l sh l� s NVAQUuyC702O <br /> y&ALTy DEpMR��N)Y <br /> ACCEPTED BY: �(II A_t/U'l, EMPLOYEE#: DATE: T / •9a <br /> ASSIGNED TO: �L EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): IL SERVICE CODE: �' P1 E: <br /> Fee Amount: ' �- Amount Pa/ Sax Q D I Payment Date <br /> Payment Type Invoice# Check# ob Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />