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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> (,Y- <br /> FACILITY <br /> C�b�rnp�7 CHECK if BILLING ADORE55❑ <br /> C t <br /> FACILITY NAME <br /> Tt? u 1 l e r�s Ta qver p� <br /> SITE ADDRESS <br /> Street Number I Direction Street Name city ZipCode <br /> HOMEoror MAILING ADDRESS (If Different from Site Address) <br /> �%y C� W TA 6"r CI CGS S \\t. Street Numbe77r Street Name <br /> CITY STATE CA ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (D130)) ('9-6 - 1 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT. <br /> Te ut le+as TC�a i CA 11�(i 6 9 S'g <br /> HOME or MAILING ADDRESS c� FAX# <br /> CITY C1STATE ZIP gs—uei <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 TE and FED"RAL laws. <br /> APPLICANT'S SIGNATURE• DATE: I 1. 0 <br /> L—PROPERTY/BUSINESS OWNEX13- OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is 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 /> Ir I <br /> TYPE OF SERVICE REQUESTED: Rpt41z.KIeAfr <br /> COMMENTS: D <br /> �Lnyr.,,' l l� (+ .S,�P 1 p ZO <br /> vV fyd SAIV. ?� <br /> A11Vl QulH CO <br /> N 4L7y D pMOV7AL 1Y <br /> MENr <br /> ACCEPTED BY: ' EMPLOYEE#: O DATE: q 0 <br /> ASSIGNED TO: 9ff �. EMPLOYEE#: /// DATE: 10 <br /> Date Service Completed (if already completed): SERVICE CODE: s� PIE: r <br /> Fee Amount: Amount Paid -qPayment Date c l b - <br /> e, <br /> Payment Type Invoice# Check# Received By: -[� <br /> EHD 48-02-025 # USR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />