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F <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> yr00530�1 <br /> OWNER I OPERATOR ry <br /> �./'��.�� /Y,� a'1 �� `��-� CHECK If BILLING ADDRESS <br /> FACILITY NAMELr�O1` � (� p11�� !�/vt <br /> SITE ADDRESS %� .S �Lt�,iJ SG`! �-•.�� ���-D3 <br /> Street Number Direction Street Nam C t O Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) LLQ 2A N�p.f�-tI ti ,� � , <br /> Street Number 6" li LS'tra'et N/am~e`1 '-' <br /> CITY S-rD0`—( — ` /P STATE A ZIP <br /> PHONE#1 v�J EZT' APN# LAND USE APPLICATION# dL <br /> (ZUe) p q 7 L <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR It SERVICE REQUESTOR <br /> REQUESTOR !� �, ,r CHECK If BILLING ADDRESS <br /> BUSINESS NAME A- l MAS 1 7 0# <br /> v 71:7 <br /> HOME Or MAILING ADDRE S / FAX# (P <br /> CITY l'� � '� J STATE pA e ZIP G1 r�� <br /> BILLING ACKNOWLEDGEMENT: 1, 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: {f /J u{ �Q ,l `K DATE: <br /> PROPERTY/BUSINESS OWNER 11 OP ATOR/`MANAGER OTHER AUTIIORizED AGENT El <br /> IfAPPL/CANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> rga rg n 0 L/ L cL0 u d , 60"r7 y "i �O NM oU010 <br /> ACCEPTED BY: lei m I EMPLOYEE#: - DATE: Rrytr . 707911 <br /> ASSIGNEDTO: A/Il (� F,'Dr1�C��JG EMPLOYEE#: DATE: IN"CW <br /> Date Service Completed (if already completed): SERVICE CODE: d PIE: / 0J <br /> Fee Amount: Amount Paid � Payment Date (;?-11g 1.2� <br /> Payment Type V18 Invoice <br /> J# Check# Received By:Lj <br /> EHD 48-02-025 `" '` It / / " ���� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />