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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST I'M 05L/2q ,3? <br /> Type of Business or Property FACILITY I.�O c SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME - - <br /> l� VICJ',A <br /> SITE ADDRESS Com, L"� t��j .7��5��✓t� � o�� -�n X520"} <br /> Street Number Olrection Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> C»'U 0 09 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME �J PHONE# En. <br /> '10N �t�tJ 2v`R ---114CIE5109 <br /> HOME or MAILING ADDRESS 'kk ,O FAX# <br /> c ) <br /> CITY STATE Com_ ZIP �SZC1 <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 /> 1 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: � U�� DATE: <br /> 11 /��/�21 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANTisnolthe BILLINGPARTY 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: I I 6EIVED <br /> COMMENTS: Nov 17 <br /> 2p21 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> �7 /� HEALTH DEPARTMENT <br /> ACCEPTED Y: WIA(0 V EMPLOYEE#: /7/ / DATE: I '� Z/ <br /> ASSIGNED TO: I EMPLOYEE#: 33 to I DATE: 17 <br /> y <br /> /I <br /> Date Service Completed (if already completed): SERVICE CODE: 0 P I E: 'I 1 nv2 <br /> Fee Amount: GJ2 'U Amount Paid Z r Payment Date Ll <br /> Payment Type V( ( Invoice# C k# 3 l f g 62) Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />