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r t <br /> SAN JOAQUWOUNTY ENVIRONMENTAL HEALT*PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> eV•c,\( �o&N ke-p c,1 CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME r {, �k -�) �V <br /> SITE ADDRESS t (0 q 9 � $eX k oma , , 5 C-C—\�'- V-\ S 20 <br /> Street Number Direction I Street Name C itv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1 g ` S� �d �a- <br /> Street Number Street Name <br /> CITY STATE ZIP 4 5 <br /> S CL��v�n 1 J <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> PHONE#Z ExT. BIDS DISTRICT l_ LOCOCODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �` <br /> J� t ,�� ��Y�01—� CHECK If BILLING ADDRESS <br /> BUSINESS NAME ` PHONE# ExT. <br /> EC��V� r��(� S�o�c` e. 2o9 S3 Fd - Llc")LlO <br /> HOME or MAILING ADDRESSFAX# <br /> 9 ©5 CLuv �l �/-� (10cf ) 2384 <br /> CITY F 5 u cv\ STATE / tk ZIP 9 5-a.2—Z!� <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,ST an(j,,FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 01t)\rCuk'-V 0 <br /> If APPLICANT is not the BILLING PARTY,proof Of authorization to sign is required Title 0 <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 environmen Ite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available andt is <br /> .provided to me or my representative ` "f <br /> TYPE OF SERVICE REQUESTED: SPP A CO <br /> COMMENTS: JOAQU 1017 <br /> HFAGT�RDNye ou <br /> 7ALNry <br /> N DEPgR MINT <br /> ACCEPTED BY: � EMPLOYEE#: 7 ] DATE: Wr 7� <br /> ASSIGNED TO: qtr)_ �Q'� EMPLOYEE#: r DATE: /y- <br /> Date Service Completed (if already c mpleted): SERVICE CODE: P/E: <br /> Fee Amount: Amount Pai �sa b� Payment Date <br /> Payment Type Invoice# Check# a2��Sc� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />