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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> IL <br /> OWNER/OPERATOR / CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 6-) V A« Z Z p <br /> 3`t 6 ( Street Number Direction Street Name —City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> n <br /> I' G e °` I b4-, Street Number Street Name <br /> CITY STATE ZIP <br /> Ltr-V ,t' <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ?07) 3 Z T 31 Zo 0053-Ja0 ) <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# EXT. <br /> �t. (s-r• SS chit.- fi ✓ (les 3L73/Z <br /> HOME or MAILING ADDRESS FAX# <br /> CITY / _ STP t ZIP <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 applicat' n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STA and FEDE L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ �l <br /> If APPLICANT 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/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. I j <br /> TYPE OF SERVICE REQUESTED: yet <br /> j f.11-6.1}JJ n u�^ , yl I7f( it vn " S c ) iG f a o/ Lo;vi Te_J Yf0L V1 l,' <br /> COMMENTS: / W i4 h r1 Htic hP <br /> (��— 1G0O7� o e%e��rcl7ec,�J�r� � e� d s <br /> b��r�► , COVVIed }lo 01061 lar�ozeWC tv S �iZ. RECEIVE,) <br /> � �' VED <br /> C�°`�� X53- 7��7 <6hIFd�16 rnspt'(4;0�1 ry"hl)► UW1 '-I� �' ��� YV2020 <br /> l C flohti� feiuv Y'ec9 ' SAN JO <br /> ACCEPTED BY: -- -j� EMPLOYEE#: D� 91 11'7 <br /> ASSIGNED TO: 4 EMPLOYEE#: DATE: j y ago auat7 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: S oZ Amount Paid 5 a. Payment Date <br /> Payment Type Invoice# Lfa' (LeU Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />