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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SRoog3sg�- <br /> OWNER/ORATOR ///'''��� <br /> r/QPeso M Cyo, z �,L <br /> FACILITY NAME ! �/rCHECK If BILLING ADDRESS <br /> � <br /> SITE ADDRESS � <br /> 1 5't7releJt Number Directron (�u Street Name od!¢/ <br /> HO E or MAILING ADDRESS If ifferent from !Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> S oCI`` C aS o <br /> PHONE#f ExT APN# LAND USE APPLICATION# <br /> .2611) '�t15-- 6 4,(6 S' <br /> PHONE#2 Eu. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTO Crur� 1 <br /> z76n- C ,? <br /> CHECK If BILLINGADDRESSE-1 <br /> BUSINESS NAMEPHONE# _//5_ <br /> / - SIT. <br /> r S c,S r e q o�(o S' <br /> HOMEOr AILINGADDRES FAX# <br /> G 11 S ( <br /> CITY 5• L2 <br /> C O C ATE ZIP S`Zo b <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,STATE and FEDERAL laws. G/ <br /> APPLICANT'S SIGNAT��URE: T t�SCI, C r0 Z DATE:I27 _ ' o .- <br /> PROPERTY/BUSINESS OWNEFS, OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> I,f APPLICAMf isnot the BILLING PARTY proof of authorization t0 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 VC4aUt>Wkwf lime it is <br /> provided to me or my representative. 1�'+/— <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: Np <br /> o d,4' � q rp SM JON NiAE -TAL <br /> VVVV � � HEFWIRO ALTH DE AR M NT <br /> ACCEPTED BY: Lot EMPLOYEE#: J DATE: <br /> ASSIGNEDTO: EMPLOYEE#: 33U7 <br /> DATE; ,W 2/ <br /> r <br /> Date Service Completed (if already completed): SERVICE CODE: PI E: <br /> Fee Amount: Amount Paid �S�Z — Payment Date � 2--/ <br /> Payment Type Invoice# Check# Received By: <br /> EHD SED 1111 �bt� /3 I SR FORM(Golden Rod) <br /> REVISED 11/17/2003 _7 �/ <br />