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J <br /> SAN JOAQUIN —OUNTY ENVIRONMENTAL HEALTH 1 ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> P&bK �Sd11S/�c�a o s <br /> OWNER/OPERATOR •�U7�l+�'��� �♦7 <br /> CHECK II BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS ';;2-4 C X I ee I a. -5 % Q <br /> l�EC <br /> Street Number I Direction Street Name city <br /> Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> PHONE#2 Ezi• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / e <br /> M,[ CHECK If BILLING ADDRES <br /> BUSINESS NAME PHONE# <br /> 1, b S-- <br /> HOME <br /> Or MAILING ADDRESS FAX# <br /> Lis- lI Sui7vlY � ( 1 <br /> CITY u--toc, STATE Co¢ ZIP p 2— <br /> BILLING ACKNOWLEDGEMENT: 1, 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 <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 JOAt <br /> COUNTY Ordinance Codes,Standards, STA/n'JtL and FEDERAL/ s. p di`- <br /> APPLICANT'S SIGNATURE: I�y ` DATE: _ L —1c) E P$J <br /> h <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ (E <br /> If APPLICANT is not the BILLING PARTY proof Of authorization to sigh 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 timC jts <br /> provided to me or my representative. - + \ <br /> TYPE OF SERVICE REQUESTED: V 61Z / <br /> 2 T <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: IL / DATE: <br /> ASSIGNED TO: EMPLOYEE#: Z1 I DATE: <br /> Date Service Completed (1 already completed): SERVICE CODE: 522 PIE: 3(002 <br /> Fee Amount: 3 O _ Amount Paid O Payment Date 1 p <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />