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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> bwvl 1�� 7 &?S-V'5v <br /> OWNER 1 OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME �r-f/ e n4 <br /> SITE ADDRESS a O a t n <br /> Street Number e I <br /> HOME or MAILING ADoREss (If Different from Site Address) <br /> Street Number Sy"t Marne <br /> CITY STATE zip <br /> ptl"E#tEM APN# Uwl)USE APPLICATION# <br /> (afl ) 3, ` - ,7 , <br /> PHONE 02 Exr. BOS DISTRICT LocATION CODE. <br /> ( <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME /j �,. Pii EM <br /> (� - - 0 <br /> HOME or Mwutw ADDRESS r fAx 1 y <br /> CITY r�[ ` STATE zip 7� <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. <br /> APPLICANT'S SIGNATURE: •r DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR t MANAGER ❑ OTHER AUTHORIZED AGENT Ved r se <br /> If t1PPLIcANT is not the,BI.LLINGP.dRTY.proof of authorization to sign is required/f 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 me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: pq y� <br /> rad1a-s iW*( v r <br /> lei Aai�drat15 -rvr in,ffi poolMayos? <br /> --- N4 V°N1"coy <br /> ACCEPTED BY: G� /�•`�t?v EMPLOYEE M 2�7 O DATE: <br /> ASSIGNED TO: �/� EMPLOYEE#: L DATE: <br /> Date Service Completed {ff already completed): SERVICE CODE: S�� PIE; Z <br /> Fee Amount: �, Amount Palow.,? o�y Payment Date 6-1611 l <br /> Payment Type Invoice# Check# 5-/)._,7 Received By: <br /> EHD 48-02-425 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> f. <br />