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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST P (Z D 5I (09 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Fiq aagW5 Sa �,j�3152 <br /> OWNER/OPERATOR //�At,,/n/,A w^, <br /> M✓LYvl,l �II✓Wl aq D CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> streetDirection - StrEet tlam J Cit _(Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) -1 vy orl (' LM COQ <br /> Street Number 7 Streal Name <br /> CITY STATE ZIP <br /> PMIE LAND USE APPLICATION# <br /> f1> k 10 - (�5l) S <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR /� <br /> �jt /n //M M n .A. J CHECK If BILLING ADDRESS <br /> BUSINESS NAME ✓✓tt I-71441 <br /> l W l;Ut rAr 6^^�"l-GOVV L L) ( V^0 0 5D S Ems• <br /> HOME Or MAILING ADDRESS Il' l FAX# L <br /> CITY sw STATE (> ZIP <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. ,�.,,// <br /> APPLICANT'S SIGNATUR` �( r( G (VVI G`4d DATE: SI-?L112 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El <br /> IJAPPLICANT 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 j3he same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: -:T76 O <br /> COMMENTS: <br /> yF9LT ROyyf COUk <br /> N08P,gRY�NT <br /> ACCEPTED BY: EMPLOYEE M DATE: 5 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amoun IS�� Amount Pa � a 0 Payment Date 2� <br /> Payment Type Invoice# Check# Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />