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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 906 0lP <br /> OWNER I OPERATOR <br /> / rl/4 q SrX CHECK if BILLING ADDRESS <br /> FACILITY NAME S ul a I / v` l <br /> 15 7 <br /> SITE ADDRESS /`'tt/, I2 `I�I� //'tI-{//,Iy/� ✓ /�S7r.�- <br /> 3 Street Number Dirion 1 I ' I ' Str¢et Name ��k ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) Jl a � ,,,I r., <br /> Street Number Street Name (/( <br /> CITY STATE ZIP -3-3 t� <br /> PHONE#� l�� E APN# LAND USE APPLICATION# / <br /> q01 <br /> PHONE#2 ( Ex . BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> C CHECK If BILLING ADDRESS <br /> BUSINESS NAME I/v PHM# E' , <br /> HOME Or MAILING ADD ESS �� FAx <br /> av- I l <br /> CITY 1- /�,In—VCA, <br /> STATE ZIP <br /> BILL1-INNG"rA1CKNO"WLEDGEMENT: 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. <br /> APPLICANT'S SIGNATURE: LJ\nh � DATE: I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHERAUTH RIZED AGENT❑ <br /> 1f APPLICANT i.r not the BILLING 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 and at thNi a�taime it is <br /> provided to me or my representative. ,n <br /> TYPE OF SERVICE REQUESTED: U" CA IA A <br /> COMMENTS: UCC,Z p <br /> O '1p <br /> Nz Ep�NT N <br /> �FNT <br /> ACCEPTED BY: EMPLOYEEM DATE: <br /> ASSIGNED TO: EMPLOYEE#: C/ DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: O P I f21� <br /> Fee Amount: -�U Qd Payment Date <br /> Amount Paid / Z 2"DCJ <br /> Payment Type Invoice# Check# Received y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 Hl-i l n <br />