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SAN JOAQUTN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST 102 1 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> nuf a C U 1�1I` ri <br /> OWNER/OPERATOR rtpi <br /> t n CHECK If BILLING ADDRESS <br /> FACILITY NAME G <br /> SITE ADDRESS IO61/Q r`//T/ Y /) "t 17 l0 7 <br /> `Street NGmber Direction �OV4� IStreet lN.a/�e /7IV � Ci �Zi Code <br /> HOME or MAILING AD ESS (If Different <br /> ave o rVl r nfrom Site Address) r(vpr <br /> evt Number Street Name <br /> CITY STATE 4�lb <br /> HONE#j �� E�' APN# LAND USE APPLICATION# <br /> 4� ' <br /> PH.OdONlE4}'('#2 ET• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> {�G O /� CHECK if BILLING ADDRESS <br /> BUSINESS NAME f t _I PHONE# En. <br /> QA{M <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE zip <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 / / V//11 / <br /> APPLICANT'S SIGNATURE: /// DATE: ` D— —�1 <br /> PROPER'L'Y/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICA Tis not the BlLLEVG PARTY proof of authorization to sign is required Title <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 an at the same time it is <br /> provided to me or my representative. .q <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 11. O <br /> N'DFaFN1�Y <br /> �F1'T <br /> ACCEPTED BY: I,-}-t— � � EMPLOYEEM DATE: <br /> I <br /> ASSIGNED TO: ? ,I - EMPLOYEE DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: _ <br /> Fee Amount: Amount Paid �' b D Payment Date <br /> `+l <br /> Payment Type Invoice# Check# Received y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />