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0 . 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Pronarty - FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> $ITEADDRE S <br /> 3treetNumber <br /> HOME Or MAILING ADDRESS (If Different from Site Address) L 3 3 �"� / /� 1-,4 <br /> Street Number street Name <br /> CITY !r r L0/;?JSTATE �4 , zip <br /> PHONE#1 ET APN# LAND USE APPLICATION# / <br /> ±2Z 1-3'-� Y- <br /> PHONE#2) � 3 �� Y <br /> Err. BOS DIS CCTvcc� LOCATION CODE <br /> L(26 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING RE <br /> BUSINESS NAMEd �1/ PHONE —3��`/�� T <br /> HOME or MAILING ADDRESS / FAX# <br /> (ZG 7) m3C � 5/ <br /> CITY STATE �X zip C/ <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 apptica' th the work be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA d FE L s. J <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPEL <br /> MA GER❑ ER AUTHORIZED AGENTAI />�/, t/�G 701 <br /> If APPLICANT n the BIR proof of aut ,AER <br /> to sign is required Title <br /> AUTHORIZATION TO RELEASE INATION: 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. w <br /> TYPE OF SERVICE REQUESTED: A- &meq e II rfE <br /> COMMENTS: VE6 <br /> SEP 12 X013 <br /> S,41V jOgOUtN <br /> HEALTH 00,gRrMJ. <br /> ACCEPTED BY: tV\ _ EMPLOYEE#: -2,6 ,y DATE. C <br /> ASSIGNED TO: �� ( �� � EMPLOYEE M l L, -2--2— DATE: <br /> Date Service Completed (if already co pfeted): SERVICE CODE: P 1 E: ,2:? <br /> Fee Amount: n s`-Y Amount Pai 375 v D Payment Date l <br /> Payment Type Invoice# Check# Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />