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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# } <br /> L <br /> OWNER 010'1 b�rt^Tri6R <br /> /`�/V �VI�/QI�I/✓ C�/ �!//YT/ ��.SLIt/�^/�Ie� .UG r / 11r�/G,CHI A BILLING <br /> FACILITY NAME cle R 4- �71yft L �z / � �/ Q.,ri✓ /dam/•l�-�/G L `✓/ <br /> SITEADDRESS //3O eJNIN% � P42 t'�rlLGU�.I �p /✓iPN t_`7 9$3 7 7 <br /> Street Number Direction Street Name City Zin Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITYS, � �j �.-,. / STATE /d ZIP <br /> PHONE#t V c�/C- C/�`� EXT' APN# LAND USE APPPLicATiON# <br /> O l0 <br /> PHONE#2 Ex r, BOS DISTRICT LOCATION CODE <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR <br /> !^' CHECK If BILLING ADDRESS <br /> BUSINESS NAME //"9t/1/ ✓V/!/� � CO�N�` �pG'/D'� ® PHO ®�rQ-b xT � <br /> J `G Q - ,?0 <br /> I <br /> F{HMC—aPMAILING ADDRESS /P� FAX <br /> ��p ,? 7•j% 1 <br /> CITY ��/�(nt/ STATE 4f54 ZIP ,V,5-2—V7 <br /> € <br /> BULLING 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 3 <br /> 1 <br /> COUNTY Ordinance Codes,Standards,STATE and FE RAL laws. <br /> APPLICANT'S SIGNATURE: itrW" DATE:_ a7 <br /> PROPERTY/BUSINESS OWNER❑ ' OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT yy �6- /WZ / '�G <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 i <br /> 1' <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 /> i <br /> TYPE OF SERVICE REQUESTED: C j <br /> COMMENTS: /CG I�/l �( RI��% �/✓S�/�C L"Al-� <br /> t <br /> Lf'E/Q/N/P`/✓t�iV� y'i2uu�e/'.D /�✓i'���2 /Y1r�/I��JRis✓cj l/t�L� , � <br /> If -1/0 7 <br /> ®7 <br /> ACCEPTED BY: EMPLOYEE#: L/���/�p��, DATE: <br /> �G <br /> ASSIGNED TO: '� � ( EMPLOYEE#: 6r,�-!Y DATE: <br /> t <br /> Date Service Completed (if already completed): L-7/07 SERVICE CODE: P 1 E: <br /> i <br /> Fee Amount: Amount Paid Payment Date <br /> 3 <br /> Payment Type Invoice# Check# Received By: <br /> 1 <br /> I <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />