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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # RVICE REQUEST # <br /> C10 <br /> OWNER I OPERATOR LLL CHECK if BILLING ADL)RE980 <br /> 6..d. <br /> FASILRY NAME L <br /> SITE ADDRESS t 7 ea •�-d �i �� <br /> 213Z' �t4° Strut Number Ofrectlan Street Name Ctty Z12 Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Strout Number ftmtNsme <br /> CITY STATE zip <br /> PHONE #1 Eno APN # LAND USE APPLICATION 0 <br /> PHONE #2 BOS DISTRICT LOCATION CODE <br /> ( <br /> CONTRACTOR / SERVICE REQUESTUR <br /> REQUESTOR CHECK if BILUNoADDRESS <br /> /h <br /> EKTo <br /> BUSINESsNAME Ar NAME 1 „ , /tA � G C P� # <br /> HOME or MAILING ADDRESS Y • t FAX # <br /> iet Caa e►,,�,,\ k 1 ) <br /> CITY 46171� O STATE / 4 ZIP AS03 <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 DFPARTMENT 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 TATE and DERAL laws• <br /> APPLICANT'S SIGNATURE: DATE: Sz1 <br /> PROPERTY / BCSHVEsS OWNER OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT © !r- <br /> Ak: <br /> IfAPPLZCdNPis not theBmLWGPARTY proof of authorization to sign is required ritte <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 COUNTYIVIRONMSNTAL HEALTH IIEPARTMENT as soon as it is available and t the same tinpQ^it is <br /> provided to me or my representative . I A YM <br /> rxAt C ENT <br /> TYPE OF SERVICE REQUESTED: �1 C M✓ w• � <br /> it C �/ <br /> F <br /> 7JL/N <br /> D <br /> COMMENTS : 020s 21 <br /> fN EN RoN l COL/ <br /> ALTy pE A TMENTY <br /> ACCEPTED BY: l Ug \ EMPLOYEE #: DATE; <br /> As&IGNED TO : v EMPLOYEE #: DATE: 40 <br /> aAAfl <br /> Date Service Completed (if already completed) : SERVICE CODE: Z a P / E: :2 ✓0 9 <br /> Fee Amount: ✓ t >7 Amount Pal �� Payment Date <br /> Payment Type _ Invoice # Check # � � L 37ql Rece ed By: <br /> EHD 46-02-025 SR FORM (Golden Rod) <br /> REVISED 11 /17/2003 <br />