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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ` <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> o �e v- � e u ��-�`� <br /> OWNER I OPERATOR <br /> �/' �� CHECK If BILLING ADDRESSpon � e� mo ❑ <br /> FACILITY NAME T COS Ln a D--r a n ca <br /> SITE ADDRESS FJ- O" 'V"1 C-1 rG n t L I n-) 1:2,CI� -meq L\y G�1 <br /> Street Number Direction Street Name Cit 1 Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) l i q I&A r I ` 1 1c)—ro`(� D y <br /> Street Number Street Name 1 <br /> CITY STATE C i� ZIP I r BI / _ <br /> Ptl?Ne#; ��� EXT• APN# LAND USE APPLICATION# <br /> PHOOfNV�EpI#2 ExT• BOS DISTRICT LOCATION CODE <br /> LL2 I, <br /> Hqqq <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> n I 0 1 ' I rC 1 CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME � C �� PHONE# EXT. <br /> 1'"1 '� <br /> HOME or AILI ADDRESS FAX# <br /> ) <br /> CITY STATE In ZIP `a -7 <br /> BILLING AC OWLEDGEMENT: 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 SIGNATURE: � (-V n 1, �L O Y 4 DATE: 1/ <br /> J <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT 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: 61n C,j cv- <br /> COMMENTS: D <br /> %FEe 09 <br /> ly,NRO)V O?U0N211Y/NDE� <br /> p <br /> AL <br /> ACCEPTED BY: a EMPLOYEE#: DATE: / <br /> ASSIGNED TO: EMPLOYEE#: DATE: �/ Z <br /> Date Service Completed (if already completed): SERVICE CODE: 3 P 1 E: <br /> Fee Amount: `1 — Amount Paid Payment Date) 2( lA <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />