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"1 <br /> t SAN JOAQU404 COUNTY ENVIRONMENTAL HEALTII DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ,5 SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> j-dZ/Q 4AOO-(:HECK If BILLING ADDRESS E] <br /> FACILITY NAME✓!�/id�C/J��/�/� /��/ _ /L GA `���G.���� <br /> SITE ADDRESS �- <br /> /� 7 Y6 Street Number I Direction city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2CZ-/0^/ tIC-- <br /> �'?/0 Street Number Street Name <br /> CITY I V/-v` STATE c,4 ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> —03 i✓s� <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR L <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMES'�� j,J � pG✓D—faID,. P.QD /a 3�O�o EST. <br /> HOME or MAILING ADDRESS n. n ROX / [r/ D IAX�# ) <br /> CITY /�A--� /tJ/� ! STATE C/� ZIP 9 ��V <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 PEDERAL laws. <br /> APPLICANT'S SIGNATURE: ' DATE: /011Z _ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT I <br /> If APPLICANT is not the BILLING PARTY,proof Of authorization to sign is required Title �+����/Q• <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 environmenia. <br /> MURIVED nt <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: JJ/2lL L 1^1(7- f��.�/1'll/ �� ��/1�EC%/�� NO V 2 Op <br /> COMMENTS: _ �� [NVJ !EA LTH�/'��<<!i✓�j ��,e/�?!/ � /ir/,T i�-�.c/�t/l � (/.,�I,r1 VPVE�M 1 S�T!'C f S <br /> G.�-/✓F C �t�✓�<'i�L , C'a- A-i�,er/��,e y sJrr �� a ,�T .tc—c�✓.��y �✓e- <br /> ACCEPTE BY Zo EMPLOYEE#: V DATE: <br /> ASSIGN*TO: NI ttCg�lEMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CO E: zoo J P I E: <br /> Fee Amount: Amount Paid Payment Date <br /> Paymentfiype Invoice# Check# � Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />