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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> P/ ZZA- f-� i�c� 00 2 "o a60,130 5� <br /> OWNER/OPERATOR <br /> M �/ M� ` 1 vvA L c o �} /�I CHECK If BILLING ADDRESS❑ <br /> -i - U 1 t ►` 1 4 I h �L <br /> FACILITY NAME <br /> rr _ py <br /> SITE ADDRESS ) a� 4'C L L.C" y IV _�v�- S T-oL.r--To ( 1 )—d--O I <br /> Street Number Direction D Street Name Ci ZI Coda <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> -� C J Ll:L� t A Street Number Street Namc <br /> CITY �! STATE ZIP <br /> PHONEIM ExT. APN# LAND USE APPLICATION# / <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> 3 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME 41�C�' i,'I2 2_ _n PHS# — <br /> Ext. <br /> HOME or MAILING ADDRESS + JJ rl FAX# <br /> 2 <br /> CITY �— ` - �{ STATE ZIP <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 an 'hat the work to be per. ` e It be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STAT and F RAL laws. <br /> ;1 <br /> APPLICANT'S SIGNATURE: I DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT isnot the BILLING PARn'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 enviromnental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMI-NTAL 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; COO So <br /> COMMENTS: D <br /> arc 2310 <br /> ( hany. Of 00ner—sh{Q "��aQ�, <br /> yFALT�jyd�1+MFH�NTy. <br /> ACCEPTED BY: EMPLOYEE#: DATE; 23 <br /> ASSIGNED TO:sffb/�y�` EMPLOYEE#: {�}�✓✓ DATE: <br /> If <br /> Date Service Completed (if already completed): SERVICE CODE: �f rP Ii ✓ �� <br /> 1. 1 <br /> Fee Arnow Amount Paid I�!1 Payment Date Z <br /> Payment Type Invoice# C CCX�# �G� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 felt <br /> en 1 _it•7 f <br />