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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or PropertyFACILITY ID# SERVICE REQUEST# <br /> Oi�HIL L 0N <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS <br /> F?f�N7clt�h. S , <br /> FACILITY NAME L 7— Ce LID �, / 7 y, <br /> SITE ADDRESS I 15 L CLJ �Y(iS E l/1L L L' LryIL�'L L OL>t �I 3 ' <br /> Sine Number DIr ion Street Name C zi cod. <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Stmcl Number <br /> CITY STATE ZIP <br /> PHONE#1 Eur. APN# LAND USE APPLICATION# <br /> ( Slut R1141 lv3 <br /> HONE02 En. BOS DISTRICT LOCATION CODE <br /> (M ) 276 / F <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR A// �I�AOlA CHECK If BILLINGADDRESS 0 <br /> BUSINESS NAME /l/V/ l,' /_l u V PHONE# �' <br /> LZ— Rc1ox CITY ' .o �9ti 961,, <br /> HOME or MAILING ADDRESS FAX# <br /> CITY f'Bi� STATE C ZIP J j <br /> BILLING ACKNOWLEDGEMENT: 1, 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,STATE and gFEDD,E(RRAAL,laws_ f <br /> APPLICANT'S SIGNATURE:, Ila ` ' DATE: I <br /> PROPERTY/BUSINESS OWNERENATOR/MANAGER ❑ OTHER AUTHORIZED AGENT /I/EK <br /> IJ'APPLICANT 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 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. PAI- <br /> -TYPE OF SERVICE REQUESTED: RF c <br /> COMMENTS: <br /> D <br /> sqN✓ ?0 ?OZl <br /> �E'q 7-p MFN°ONrr <br /> ACCEPTED BY: C�I. . L IiYYL'L EMPLOYEE#: DATE: i Z)20 I <br /> ASSIGNED TO: �Lv�v EMPLOYEE DATE: <br /> Date Service Completed (H already completed): SERVICE CODE: �, ) PIE: <br /> Fee Amount: 5 Z Amount Paid' �5�. �� Payment Date <br /> Payment Type 't I Invoice# Check# d Received By: <br /> EHD 4 � �T , (,I SR FORM(Golden Rod) <br /> REVISEDED 1111 17/17/2003 �1•� tl <br />