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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ho <br /> VF,+P-RflNS Se RV1Cd 01ZQ c <br /> OWNER 1 OPERATOR <br /> V F bJ?0Sf 05 CHECK If BILLING ADDRESS <br /> FACILITY NAMEy7 <br /> SITE ADDRESS V �j �r� KGl !C I *0/J <br /> f� Street Number Direction tr et Name CItyZ€ Cotle <br /> FIQME or MAILING ADDRESS (If Different from Site Address) <br /> •0• Street Number Street Name <br /> CITY + a STATE ZIP QSJ(00 ' <br /> PHONE#1 WExt. APN# LAND USE APPLICATION# <br /> [PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> f I ' <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> � EZA) ?O 6. - t,0,5 1 CHECK If BILLING ADDRESS L� <br /> BUSINESS NAME V OF ) PO4 I !ro "7,/ PHONE# d p ExT' <br /> HOME Or MAILING ADDRESS FAX <br /> 7• dim f 1 <br /> CITY R € 0 N STATE CA_ ZIP 9671041 <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. l OZ 1?/UH Zoe <br /> APPLICANT'S SIGNATURE: y- DATE: J4W4k 47, <br /> PROPERTY t BusmEss OWNER13 OPERATOR I MANAGER ❑ OTHER AUrHORlZED ACENTIZ Q(,t Lt&4,-A"-&4_ <br /> If APPLfC9NT is not the BILLING PARTY,proof of authorization to sign is required Ti rle <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 enviromnental/site assessment <br /> information to the SANT JOAQUIN COUNTY ENVIRONNIENTAi.HEALTH DE,PAR'I-NIEN'r 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: F{*TL`i 4p/J <br /> COMMENTS: <br /> C s" <br /> + � ,�N J UN <br /> s <br /> SEA"r pQt//,V MEIy�UNTy <br /> A qG <br /> ACCEPTED BY: ohm EMPLOYEE#: DATE: <br /> ASS€GNED TO: EMPLOYEE#: I Top DATE: <br /> Date Service Completed (if already comple ed): SERVICE CODE: I u n P'/E: <br /> Fee Amount 1c;3, �Ou Amount Paid"9-/SaZ> Payment Date ('p <br /> Payment Type Invoice# Check# Recei ed By: <br /> am <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br /> V MI 001 IS <br />