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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# /n�SERVICCEE REQUEST# <br /> '00Q/`I-0 <br /> OWNER/ OPERATOR <br /> \` ✓I/� l� e ( CHECK If BILLING ADDRESS <br /> FACILITY NAME W I A el �Od Wd-�- <br /> SITEADDRESS51�C�jDti � v <br /> -Z5 <br /> Jl) Street Number Direction Street Name city Zip Coda <br /> HOME Or MAILING AODRE S If Different from Site Address) <br /> 2—�6 6 Street Number Street Name <br /> CITY t G� STATE ZIP <br /> PHONE#tt-� _ ExT. APN# LAND USE APPLICATION# <br /> ('rt ) �((S-1(fl-��5-1 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> R.EQUESTOR <br /> L Vh rq Q CHECK If BILLING ADDRESS <br /> BUSINESSNAME 1 PH NE# En. <br /> HOME or MAILING ADDRESS FAx# <br /> `off <br /> CITY ��1.✓k� klU/� <br /> 13U CLG YlVN t (/-F` 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 appli ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ST d FEDERAL <br /> APPLICANT'S SIGNATURE:IQ kDATE: _ �� Z <br /> PROPERTY/BUSINESS OWNER❑ 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. P <br /> TYPE OF SERVICE REQUESTED: u, RF `r♦�' <br /> COMMENTS: 140 <br /> MAR � <br /> Ai <br /> � ?0 <br /> H pFugRNT ?t y <br /> �FNT <br /> ACCEPTED BY: .A/I kOM EMPLOYEE#: DATE: <br /> ASSIGNEDTO: VAI <br /> IIt6 EMPLOYEE#: DATE: l� <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount A 101 Amount Pa lsa 0b Payment Date 3 z <br /> Payment Type Invoice# Check# �� G[SZ���I Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 11- A <br />