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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# =30, <br /> ERVICE REQUEST# <br /> A00101L4�- 0201 <br /> DOWNER/OPERATOR I I /// <br /> CHECK If BILLING ADDRESS . <br /> FACILITY NAME l <br /> i <br /> SITE ADDRESS <br /> ^'SRe4t 1mber Dlr2ct@n 1 —$tt¢eI Name i ZJi CoJdlet/'C/ <br /> HOME Of MAILING ADDRESS (If Different from Site Address) �� <br /> ` <br /> C- - Z <br /> i Street Number Street Name <br /> [CITY ' '1 n STATE A ZIP / 5L;-6( <br /> PHONE#1 / �("��,'t Ex'. APN# LAND USE APPLICATION# `�� (O <br /> ( ) "V l uV-I O <br /> PHONE#2 E+ . BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR� <br /> i..--'- CHECK If BILLING ADDRE5AI <br /> 'BUSINESS NAMES `-ILV, �f LLVv PHONE# <br /> HOME Or MAILING ADDRESS //�� �''((��\I/�1 ��.\J. �/7� FAX# <br /> +CITY' I� (\ STATE r ZIP �2 2 to/fsn <br /> BILLING ACKNOWLEDGEMENT:\KNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized ageentofsame, <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 prepare lication and tat the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stan rds, S�TE and FED IRA laws. r <br /> `APPLICANT'S SIGNATURE: l [DATE: I` I � I�l <br /> PROPERTY/BUSINESS OWNER OPE TOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT s 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. <br /> TYPE OF SERVICE REQUESTED: -I�( Q C SulJ <br /> COMMENTS: muWf 04' V.W /akttt W 0 <br /> �Rp�iN <br /> NPIP <br /> ACCEPTED BY: yy f no EMPLOYEEM DATE: <br /> ASSIGNED TO: 1_•`,I� I,r / EMPLOYEEM DATE: �V <br /> Date Service Completed (if already completed): SERVICE CODE: '0� P 1 E: <br /> Fee Amount: wJ2 00 Amount Paid IV a �� Payment Date <br /> Payment Type elholllel Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 ( WW 3tol p a i S <br />