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SAN JOAQUL . OUNTY ENVIRONMENTAL HEALTH PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property J6 FACILITY ID# SERVICE REQUEST# <br /> =to , A- DDD �� <br /> OWNER/ 7PERA <br /> � Z J �rC) <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME r Oo ^ I _ f I /� /� <br /> SITEAD//DD�RESS 1 1\/l(l(` tot,'�. U m�Ck� q` 3?1 "� <br /> 5 (J Street Number Direction GIC 1 Svlreel Name J Cll l Zip Code <br /> HOME or MAILING ADDRESS (If Different fromSite <br /> v <br /> Site Address) li lF <br /> V Street Number �v' '"r 18lreet Name <br /> CITY Cl kD cW v n STATE ZIP <br /> J � <br /> PHONE#1 EZT. APN# LAND USE APPLICATION# <br /> (c;l0 5b - los <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( 9) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> �',n 1n n �Q� CHECK If BILLING ADDRESS <br /> BUSINESS NAME 0 1�'�`r�tvn. (510 ('�25 ExT. <br /> HOME Or MAILING ADDRESS 'a)w ke FAx# <br /> 5 P �iC 16A I ( ) <br /> CITY '_` C"'I NA <br /> STATE ZIP �o—�- <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,Standar s, STATE a DE laws. --7 n <br /> APPLICANT'S SIGNATU E: I v� DATE: T 0 O <br /> PROPERTY/BUSINESS OWNER OPS TOR/MANAGER ❑ O'HER AUTHORIZED AGENT <br /> IrAPPLICANT 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/siFAVY"T <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the wmmmVED <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ` I/� RGM✓ <br /> IS I n JUL 2 F1021 <br /> COMMENTS: <br /> I SAN <br /> ENVJOAQUIN <br /> RONME TALTM <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: 'f I q EMPLOYEE M ��Y3� DATE: -7 2/ <br /> ASSIGNED TO: 1 EMPLOYEE#: 35(f I DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: IOU <br /> I P/E: 2 <br /> Fee Amount: Amount Paid # /<< Z � Payment Date <br /> Payment Type Invoice# l 6He k Vg'# /Z 6 Received By: <br /> r <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />