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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY lD# SERVICE REQUEST# <br /> to/ zz� �cs'�GctrA$7 <br /> OWNER I OPERATOR <br /> ACHECK if BILLING ADDRESS <br /> 114 <br /> err, l"5 /r/1 p�ih or <br /> FACILITY NAME <br /> SfTE ADDRESS / 7{K�F'i' 7'►�veeY CIS�7�0 <br /> Street Number DireetlOn Street Name C Zip Code <br /> NOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr• 7PN# LAND USE APPLICATION# <br /> (719,1 ) 737 Zo3 <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME 1!� -�J� 4t l y� PHONE# Exr• <br /> AH IZ 1 v wH 7�►^bcti � �6D Sz! �-f i Z7 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY r G STATE Gro ZIP cJ s5aq <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 ENviRoNmENfAL 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 FEj)ERAL laws. <br /> APPLICANT'S SIGNATURE: ^ DATE: '`2D2 <br /> PRQPERTY/BUsmss OWNER® OPERATOR/MANAGER ❑ OTHER AUTHOR1zuo AGENT❑ <br /> If APPLICANT is not the BILLING PAR7Y,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. d <br /> TYPE OF SERVICE REQUESTED: 14q YM <br /> CaMxl:errs: fAza <br /> o m wy,� JA E'VE� <br /> . "U N 11 ?0 <br /> avw-�/NCOU1� <br /> �ACTj�pE;4 1Y <br /> ACCEPTED BY: EMPLOYEE#: DATE: ��� i <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: W1 I <br /> PIE: <br /> Fee Amou ` � Amount Paid f Payment Date121 f-1 <br /> Payment Type Invoice# # ; 3 Received gy: <br /> EHD 02-025 SR FORM(Golden Rod) i~ <br /> REVISED 11/1712003Y'J `�J <br />