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SAN JOAQUIN . -UNTY ENVIRONMENTAL HEALTH L iRTMENT <br /> SERVICE REQUEST <br /> Type of gsine s or Property FACILITY ID# SERVICE REQUEST# <br /> � W -�7a- uo-� IP] a D <br /> OWNER I OP�FRATOR_ <br /> 9 ( ( /I �/ `, CHECK If BILLING ADDRESS <br /> FACILITY NAME I , /•� \ II I <br /> SITE ADDRESS <br /> Street Number Dirogtion /1 treat N-111"--- <br /> HOME <br /> a HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Nae <br /> CITY STATE ZIP <br /> PHO E 1 EXT. APN# LAND USE APPLICATION# <br /> ( / ) <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR '/J KE ,Wj )Op „ // <br /> `',/ /fit e/ C( CHECK II BILLING ADDRESS <br /> BUSINESS NAME µ��5 ��,�r// C peer �LO PH NE# EXr. <br /> / I ��'-Il V r1/69Y7-1672. <br /> HOME Or MAILING ADORE�SS� /�L�[ F // <br /> ( (�•) O O <br /> CITY STATEe,4 ZIP 9S Z <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 /> 1 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 FE ERA aws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OT RAIITHORIZEDAGENrEr e4'*72-ee7- � <br /> If APPLICANT is not the BialyG PART P proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 nae or my representative. <br /> TYPE OF SERVICE REQUESTED: S-e In I e / (L-e M p • I G� p <br /> COMMENTS: eCeIVZ6 <br /> RAk 17 <br /> ?0 <br /> Fav✓oqQ ?0 <br /> NRgt N50- , COUN <br /> ACCEPTEDBY: 7 ��e n/1�� EMPLOYEE#: DAT . 20 <br /> ASSIGNED TO: V �V CL�/In EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: s PIE: 3(a oz <br /> Fee Amount �L — Amount Paid Payment Date <br /> Payment Type Invoice}# Check# Received By: <br /> EHD SED 1111 0,'pl p-(-i— a I —tya�l SR FORM(Golden Rod) <br /> REVISED 11/17/2003 (V1 � � <br />