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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> s 5K008ia73 <br /> OWNER/OPERATOR ,n�Jl W r`4 CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME V <br /> SITE ADDRESS u`' S <br /> Street Number I Direction �(Stre ame ���C t Zi 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 /> 0`37040 <br /> 0 <br /> PHONE#Z EXT. BOS DISTRICT--7LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ✓n�`/ )��u� CHECK if BILLING ADDRESS <br /> JI JJ <br /> BUSINESS NAME f P� �t r-p( � P EXT. <br /> ZC � 3 <br /> HOME or MAILING ADDRESS f FAx# <br /> CITY J{ I STATE C ZIP S z 3 <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 SIGNATURRE: ` k/, L, �J'/ DATE: / 0 -11r-(- <br /> PROPERTY/BUSINESS OWNER Ea/ <br /> OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILGING PARTY,proof of authorization to sign is required Tip <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the pr lie <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environme Q� sw ent <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available all the saiTfe ill is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: Vt JS L� �v"1 j I�S M—) �'�N`� h �r —uu <br /> rZA <br /> 0 � � �. <br /> ACCEPTED BY: " EMPLOYEE M / DATE: <br /> ASSIGNED TO: EMPLOYEE M G DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: U / P I <br /> Fee Amount: 2 Amount Paid Payment Date 1� <br /> s 1 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />