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SAN JOAQUIL _,OUNTY ENVIRONMENTAL HEALTI-, .PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER! OPERATOR ",/ e IT esi t <br />M ; /V t-z_ mc..61)11., /2MEswrz CHECK if <br />4\ <br />BILLING ADDRESS <br />FACILITY NAME <br />t1/4/k C.13;11;^'I-- <br />SITE ADDRESS <br />2i51 Street Number <br />S <br />Direction <br />E.‘... Do rA DA sai-ree4_ <br />Street Name <br />s To e- V, Tft 04 <br />Cite <br />9 CZ 14 lo <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Cm( STATE ZIP <br />PHONE #.1 Exr. <br />(vb) gei 3 -1 •I I r <br />APN # <br />tib7 -oSo - ..z..) <br />I LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) II <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />z)) 4 c- Is‘IN C•) <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME .• • <br />8-div Priv-20 czo 4-\\h'rc..,"ste413r/41):1-P* PAE4) <br />EXT. <br />4 la -7 - lot.‘o <br />HOME or MAILING ADDRESS <br />S37 skagsvd Root° <br />FAX # <br />(2%)11) 4% 7 - t) g <br />CITY s-r ,Q.clk To f-d STATE C. joi) 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, ST ATE and FEDERAL laws. <br />DATE: <br />PROPERTY / BUSINESS OWNER!: OPERATOR / MANAGER 0 OTHER AUTHORIZED .-GENT A )4 <br />3 2,4 let r •Vidl, CrAz,.." <br />II-APPLICANT 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: P I E: <br />Fee Amount: Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />APPLICANT'S SIGNATURE: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003