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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # §gRVICE REQUEST # <br /> OWNER / OPERATOR `` iE \ I _ <br /> J S � L N � R44 SE � I Iv-� CHECK If BILLING ADDRESS <br /> FACILITY NAME M � N 5� 1; -` A D t �. P N/1 _ I <br /> SITE ADDRESS 11 E:L <br /> PAk1N >1 E—L7JStreerection Street Name City Zip Code <br /> HOME Or MAILING ADDRESS ( If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE #1 EXT. APN # LAND USE APPLICATION # <br /> ( SID ) <br /> PHONE #Z EXT• BOS DISTRICT LOCATION CODE <br /> c 2D ) <br /> 609 - o \ ` <br /> 11 7711 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR , S 1�5 IJZ � R.pPE N't� ( C.0 is CR-►4-LIUP- <br /> J 1 \ 'Dj `k M01i6 N CHECK If BILLING ADDRESS <br /> BUSINESS NAME S , MMAs3 S T1Z)EE 1 HV0 PCM P M PHONE # EXT. <br /> HOME Or MAILING ADDRESS \ ` S KM „ ���-T FAX # <br /> 1 1V t ( ) <br /> CITY N\ "�rVF-Lh STATE LA, ZIP 9 <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 and FEDERAL laws . <br /> APPLICANT ' S SIGNATURE : DATE :PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY, proof of aur <br /> thoization 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 : <br /> COMMENTS : S � 3 �O <br /> %q NV RoQO�N <br /> Th' O ANT y. <br /> ACCEPTED BY : (�Yzue� V � EMPLOYEE # : DATE : <br /> ASSIGNED TO : �J Qto - t /( Qwr EMPLOYEE # : DATE : <br /> Date Service Completed (if already completed) : SERVICE CODE : l� �r P / E : Q <br /> Fee Amount : LI Amount Pal / � � Payment Date <br /> Payment Type G h Invoice # Check # 2 3 S Recei ed By: <br /> EHD 48-02-025 SR FORM (Golden Rod ) <br /> REVISED 11 / 17/2003 <br />