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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Tyg!of Business or Property FACILITY ID# SERVICE REQUEST# <br /> +a.i I a.ke DpnuA N S- t <br /> OWNER/OPERATOR i <br /> CHECK if BILLING ADDRESS <br /> NOW L0 yl <br /> FACILITY NAME GT <br /> ISlrewat NIulmbJrer Dire�dl c�n \J � 1 cx} <br /> 60 1 R.•` CU✓SITE ADDRESS Street Name I;L0 q1"Cl^J2 rb <br /> � <br /> Zt Code <br /> HOME Or MAILING ADDRESS (If Different fro�Tm Site Address) <br /> W Street Number Street Name <br /> CIN STATE zip <br /> PHONE91 APN# LAND USE APPLICATION# <br /> PHONER SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Nav <br /> rt CHECK if BILLING ADDRESS <br /> BUSINESS NAME S uun Sh t vN^ DO n�l � � PHONE# ba_ 15 " <br /> HOME Or MAILING ADDRESS 19,0\.• ^ _clin St, � 5 (AX# ) <br /> CITY Q ` O� U Y p STATE C d1_ ZIP 01153 f <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,Standar s,STATE and FEDERAL laws. t J <br /> APPLICANT'S SIGNATUREE: 6—<Z—� DATE: l — ILA -'m <br /> PROPERTY/BUSINESS OWNER5Y OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICAVT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 environmentallsite assessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it i5 available andFl ME!We it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Cb <br /> COMMENTS: AM <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: I EMPLOYEE#: DATE: <br /> ASSIGNED TO: IE EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): <br /> CIs f SERVICE CODE: !L P l E; Ut D/L <br /> Paymet Date Amount: Amount Paid l 'dZ <br /> Payment Type Invoice# Check# Receive <br /> By: <br /> EHD �j U ) u� SR FORM(Golden Rod} <br /> REVISEDSED 11 11/11 7/2003 r <br />