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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> wk�m OQ P,®®9!�)' <br /> OWNER/OPERATOR <br /> \'fA\tv * `I,\1Ay\v*Q N CHECK if BILLING ADDRESS <br /> FACILITY NAME M6,\\\�� `" 1 V�` <br /> tJu <br /> SITE ADDRESS —loct �j\�l� <br /> Street Number Direction Str t Name J i INS 1 Zip Code 1 <br /> HOME or MAILING ADDRESS (If Different from SiteAddress) <br /> IL <br /> L L' o E e t`V ; Street Number Street Name <br /> CITY <br /> 9 Ci n STQ ZI�520 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> �'`\\/�l`�� CHECK if BILLING ADDRESS <br /> BUSINESS NAME u\V \ , V` IJ` IJV PHONE# EXT. <br /> \� A40 M .(2!?L.LSvc - ��13S <br /> HOME or MAILING ADDRESSreq FAX# <br /> 2CJ I wav-�5 ,oue ( ) <br /> CITY STATE CA ZIP 97 <br /> 0 <br /> 1 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 bu ess as identified on t ' form. <br /> I also certify that I have prepared this app 'ation and that w rk o be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,standards STA <br /> APPLICANT'S SIGNATURE: DATE: 1� I Iw IZV <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑� <br /> If APPL/CANT 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 /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: do <br /> H ' '1 Nw <br /> y0FpMFH'U <br /> ACCEPTEDBY: \ EMPLOYEE#: DATE: <br /> ASSIGNED TO: 1,�.� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: (i <br /> Fee Amount: t i Amount Paid Payment Date I I v <br /> JW1 r <br /> [Payment Type Invoice# e # 1 l 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />