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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Lact 11 S'0' ()0Uo 2 I <br /> OWNER/OPERATOo Ca CHECK If BILLING ADDRESS❑ <br /> �-eY�z w�z <br /> FACILITY NAME r�/y <br /> SITE ADDRESS J Vl 9S 2— <br /> uU11 55 I,� i <br /> 55treetNumber Direction L- Cy`a((,t`etN e <br /> HOME or MAILING ADDRESS (If Different from Site Address) ��jj�� r� 42 Q(!e S <br /> S eAulhb.r V ` T Street Nle e <br /> CITY Sy STATE ZIP JS .� T� <br /> PHONE#1 Y E"T• APN# LAND USE APPLICATION# "� �/J <br /> ( 0�1 S so <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR eSsio p�( . Sa z <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME -t������ n J PH E �� 6EXT. <br /> r ek d O <br /> HOME or MAILING ADDRESS FAx# <br /> CITY STATE 0A <br /> ZIP IS <br /> `)e <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,Standard STATE aGd�F <br /> APPLICANT'S SIGNATURE: <br /> j p 15�2©Zo <br /> DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PAR 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: ail L <br /> COMMENTS: <br /> y 'ya4�01Q <br /> oU�'�'li <br /> FP,1RT Tq�HIY <br /> /� M <br /> ACCEPTED BY: ,t�/�,Il,/�,t/tn 1 EMPLOYEEM DATE: <br /> ASSIGNED TO: 1 •_�/� !lr w EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: aFi Amount Paid — — Payment Date 10':5120 <br /> Payment Type Gl. 1 Invoice# Check# Received By: <br /> EHD 48-02-025 � : ��15F) g SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />