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SAN JOAQUIN JUNTY ENVIRONMENTAL HEALTH L ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER! OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />5 1' E(fA LvAnaer NI AnNtr-A-t,'r\r fQ r) <br />SITE ADDRESS S .7 -5- <br />Street Number <br /> • <br />Direction <br />R A zEtr 0" A v Qr..- t <br />Street Name <br />5 TocAc. I tli" <br />City <br />q St. o 3 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Crry STATE ZIP <br />PHONE #1 EXT. <br />(.1...) '1%1.5 's '7 '7 77 <br />APN # <br />i V -7-- 12-0 - Q 5 0 <br />LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />.----7—, REQUESTOR <br />...../1 P-1 a E ) ) A / CHECK if BILLING ADDRESS RI <br />BUSINESS NAME ....a===mciourAvice_411:ww A <br />Cto <br />a vArvcE 0 % <br />D EntlitonmEe‘444 ) <br />PHONE # <br />( L ) oc1 Lik0 -7 - /00 <br />EXT. <br />‘ro <br />HOME or MAILING ADDRESS <br />igzA.)0 <br />FAX # <br />(Ws ) 410 7— )1 \ <br />CITY S-FOCWT 0 irN <br />STATE ,- f, ZIP t 1 "" -- <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, ST ATE and FEDERAL laws. <br />DATE: 57 / 2^ Z-0 1 <br />PROPERTY / BUSINESS OWN ER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT,Igc 142,,s Eci-ivAG- <br />If A PPLICANT 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 same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />ASSIGNED TO: EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: P1 E: <br />Fee Amount: Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />APPLICANT'S SIGNATURE: <br />EHD 48-02-025 <br /> <br />SR FORM (Golden Rod) <br />REVISED 11/17/2003