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SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ox� 1'-4 2 SQ 0 0S2cl <br /> OWNER/OPERATOR I. <br /> C <br /> l� CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME 4E>\N1 /1/�pv l I o� <br /> SITEADDRESS C53o� C/` ? p��� C, Axe- Q152c):+ <br /> Street Number I Direction Street Name l) Cit 1 Zio Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> C ALL A V,1 <br /> Street Number Street Name <br /> CITY STATE ZIP !�yj <br /> d r -, e-0 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( Illy) `Z 90 1v <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME 5����}- S�hS � PHONE# �, Exr. <br /> HOME OC MAILING ADDRESS (� /���� � �✓� � FAx# ) <br /> CITY / I'` f ! CI STATE ZIP �L y <br /> BILLING ACKNOWLEDGEMENT:/KNNOWLEDGEMENT: 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, STATEAnd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: \ DATE: J2 . u A(/ <br /> ` 2- 0 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is 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.the same time it is <br /> provided to me or my representative. /•SAY <br /> TYPE OF SERVICE REQUESTED: C' �� Vf)�. c�� <br /> COMMENTS: C 1 V" JO(, o# 20 <br /> l M RONINC <br /> TyOF�A1 14>r <br /> ACCEPTED BY: ' 1 U I1 EMPLOYEE M DATE: A <br /> ASSIGNED TO: M 1% EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: b'�1 P 1 E: <br /> Fee Amount: Amount Paid r. Payment Date <br /> Payment Type ��> Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />