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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER//OPERATOR <br /> CJ o amao CHECK If BILLING ADDRESS <br /> FACILITYNAME ` U1-U ana <br /> SITE ADDRESS <br /> Street Number DS'.lrecton Street Name Cit ZI Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) 1 1_ Lt <br /> 1 <br /> O 1�a` V1V SlreeVt/Num1ber rt" Street Name <br /> CITY (' ` O� STATE ZIP vl n�^I O G <br /> PHONE#1 \V r Ems. APN# LAND USE APPLICATION# L J <br /> (109) �ti3- 353N <br /> PHONE#2 ExT BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / RVICE RE UESTOR <br /> REQUESTOR \^ ^ O CHECK If BILLING ADDRESS <br /> BUSINESS NAME U U PHONE# E.T. <br /> Lv� v qn� ge�U S by 353y <br /> HOME or MAILING ADDRESS ' (AX# ) <br /> CITY O� -T M STATE ��l ZIP q5 c15 <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. G� <br /> APPLICANT'S SIGNATURE ��� C��\ ` V1\)�V DATE: <br /> ROPERTY/BUSINESS OWNERI OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> 1f 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 l�6'dtlfl �tps <br /> provided to me or my representative. <br /> MCF <br /> TYPE OF SERVICE REQUESTED: ,e <br /> 4;d Ivr- <br /> COMMENTS: <br /> SAN JOAQUIN COU TY <br /> ol�`Por ENVIRONMENT <br /> HEALTHDEPARTM NT <br /> -s <br /> ACCEPTED BY: LAAQ/� c ,r EMPLOYEE#: D DATE: �{ / <br /> ASSIGNED TO: /,f�/� v EMPLOYEE DATE: ✓ <br /> Date Service Completed (if already completed): SERVICE CODE: P E: <br /> Fee Amount: 5 'U Amount Paid 5 �_ Payment Date d <br /> Payment Type Invoice# Check# Received y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />