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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (25 <br /> sI\v �I <br /> OWNER I OPERATOR <br /> 5 �APnz CHECK If BILLING ADDRESS Ey <br /> zQU. <br /> FACILITY NAME <br /> SITE ADDRESS 7Z, W Oo WN,4/`F /Z0- 1r:RC-1qC(4CAv)t F '75 a 3 f <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) / ! 2E:D WA k O CT. <br /> Street Number Street Name <br /> CITYSTATE ZIP <br /> l(ZA GA �3 <br /> PHONE#f EXT• APN# LAND USE APPLICATION# <br /> (6-10) 74,0 - 3 93 7 7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> tO _ J �� `, CHECK If BILLING ADDRESS <br /> FeF <br /> BUSINESS NAME(/ /V j PHONE — EXT. <br /> O <br /> HOME or MAIG ADDRESS �•t FAX# <br /> LI <br /> ( ) <br /> CITY - - R`O C—g <br /> ` Sr <br /> STATE /I ZIP 3 G <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 1 have prepared this appli tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, :and FF I..laws. <br /> APPLICANT'S SIGNATURE: DATE:.,/ <br /> PROPERTY/BUSINESS OWNER❑ OPFRATOR/ 1.ANA(;ER ❑ ut''.11AtTttoetzED.�AGE�vTa <br /> IJ A/t t.tC.l;v't'is not the BILLGVG 1,1871 proof of ant nrization 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 HEALTEI DEPARTMENT as soon as it is available and at theme time it is <br /> provided to me or my representative. AY <br /> Iry <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: NR 3 O <br /> RQ�1NC <br /> �TyOEpgR��N7Y <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: DATE7 az, <br /> ASSIGNED TO. EMPLOYEE#: «S� t DATE: w <br /> Date Service Completed (if already completed): SERVICE CODE: �' PIE: <br /> Fee Amount: Amount Paid ,36 ,Q Payment Date', 3�S <br /> Payment Type Invoice# Check# &Val d By: <br /> 192 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />