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r' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ::1 �'� S 3 <br /> OWNER/"PERATO ' <br /> Iv /'/V� CHECK If BILLING ADDRESS <br /> FACILITY NAME 1^V/� /���/� Q� '� � <br /> S E D R Dlreni� r I` lJ�l(_/ (e�N�rn�� lX/ �' I ZI Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Adie(ss) `t <br /> Street Number Street Name <br /> CITY (/1 STATE I i ZIP <br /> PHONE#1 E7APN# LAND USE APPLICATION# <br /> (5(0) 44-o 7v-FG <br /> (C ,4L4a1gn x' BOS DISTRICT5 LOCATIONrC�ODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# En. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY STATE ZIP <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,SZATC117171TWERAL laws. 4 n2 <br /> APPLICANT'S SIGNATURE: Qor) DATE: ` 23 <br /> 11 ��[[, <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER UTHORIZED AGENT 11 <br /> IfAPPL/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 the ft y time it is <br /> provided to me or my representative. As <br /> Iy�Ic <br /> TYPE OFF SEER�VICE REQUESTED: (\ � de� - C(IV f <br /> Comm <br /> V1r\�+ 1�{��-�/•W� �"`-' -.�`.' �✓ ,QUI�3 �O�! <br /> 1 ` N 0 FIV ry <br /> '9RT'yfFNr <br /> ACCEPTED BY: �� �t Ld'it s EMPLOYEE#: P DATE: -3 72) Z/ <br /> ASSIGNED TO: 7� IVC, EMPLOYEE#: 1 GO 1 ]0 DATE: (4-13-Z9 ' <br /> Date <br /> Date Service Completed (if already completed): SERVICE CODE: 0(0 PIE:/ 3 <br /> Fee Amou t:tl <br /> Amount Pal t sS�t X Payment Date <br /> CJ <br /> Payment Type (ix " Invoice# I Clvhteck#r- /2 ZS 32 Received Bi: <br /> EHD 48-02-025 `�' SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />