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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> '5Uo L t'T��I � `�v Wf w <br /> OWNER 1 OPERATOR G <br /> CHECK it BILLING ADDRESS <br /> ,�—TEZA <br /> FACILITY NAME <br /> 04— c S Ci�A cz-�-S ] L—C— N l Z, P, l� <br /> SITE ADDRESS I ` � <br /> —J 7 Street Number Street Name city 7ip33 <br /> Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> ZZ-71 l/. E v 1= Street Number Street Name <br /> CITY STATE. ZIP <br /> I-All,I,-VI�c A c A , -1 S 3� <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (-Z�) gZS -3ZV0 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> `' CHECK If BILLING ADDRESS <br /> BUStNEss NAME �Q PHONE# EXT. <br /> cg s�71- zz3Z <br /> HOME or MAILING ADDRESS FAX# <br /> I tG E-1 A t>Fi ( ) <br /> CITY /-/("L— STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> Ll <br /> knowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> ctivity Will be billed to me or my business as identified on this form. <br /> so certify that I have prepared this applicatio tat the work to be performed will be done in accordance with all SAN JOAQUIN <br /> UNTY Ordinance Codes,Standards, ST L laws. <br /> PLICANT'S SIGNATURE: DATE: b/w aj I ZvZD <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHERAUTHORIZED AGENT <br /> If APPLICANT 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 attsame time it is <br /> provided to me or my representative. /� <br /> TYPE OF SERVICE REQUESTED: L <br /> COMMENTSJAN <br /> : <br /> °kMCrunrn` <br /> �oEp,�rM�kr <br /> ACCEPTED BY: Low EMPLOYEE#: 10 <br /> DATE: <br /> ASSIGNED TO: EMPLOYEE#: ✓✓✓ DATE: & <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: 11A <br /> Fee Amount 5� Amount Paid �� Payment Date <br /> Payment Type Invoice# I Check# a Recei ed By: <br /> U <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />