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SAN JOAQUL. —''OUNTY ENVIRONMENTAL HEALTH _ sPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNE I PERATOR <br /> V y lS v 1 CHECK If BILLING ADDRESS <br /> FACILITY NAME a <br /> U <br /> SITE ADDRESS <br /> Street Number Dlraction ��O��S1reat Name J ��CII �� "Z�D� <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> T-- CL 5i Street Number Street Name <br /> CITY l✓r_�\A CA 11 � ]V ^ STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (*q) �(7 Li • Lal <br /> PHONE#2 E';r• BOS DISTRICT LOCATION CODE <br /> a3Y) q05 Sa a- <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �rr <br /> V <br /> � `•-'z— CHECK if BILLING ADDRESS <br /> BUSINESS NAME / 1 rn �I r'll�/,I PHONE# r <br /> 1 VAS V 1�r D <br /> HOME Or MAILING ADDRESS �, FAx# <br /> ao �cu� S I , <br /> CITY c ,/� Y1 Gh �rw ",aA SSTATE 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 a d FEDERAL law$. <br /> APPLICANT'S SIGNATURE:Standards STATE <br /> DATE: Z / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT 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 environ �Is,,Ie assessment <br /> information t0 the SAN IOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available e it is <br /> provided to me or my representative. /e <br /> TYPE OF SERVICE REQUESTED: JAIZIJU <br /> COMMENTS: 1021 <br /> e�/RQUtNCOU <br /> MFACTyOEP Etyrq�IY <br /> 'I <br /> ACCEPTED BY: Lq 1A CO EMPLOYEE M q000 DATE: 7 /13/2 1 <br /> ASSIGNED TO: EMPLOYEE#: $191 1 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 0 I P I E; IL/03 <br /> Fee Amount: 15� 'Q Amount Paid16a r Payment Date -9-11317-1 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />