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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> : I skoOWNC <br /> OWNER/OPERATOR �• r / _ V� O e �r'I�� CHECK If BILLING ADDRESS❑ <br /> FACILITY NA VICE Y' SQ(�; J / <br /> SITE ADDRESS /'1 (./ni�,I1` /rte L <br /> lo CWII'r(/��Lf , <br /> CIt� (� �`✓- C`(/..J <br /> Street Number Dlractlon 1 <br /> HOME or MAILING ADDRESS (If/�D17nt from Site Address) r/1t/I <br /> 2 % Street Number Street Name <br /> CITY st �J 1 STATE ZIP <br /> PH E#1 J 1 Ems• APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> (} CHECK if BILLING ADDRESS <br /> BUSINESS NAME L6 � / LIZ I PHONE# to <br /> 55 _ <br /> HOME or MAILING ADDRESS �1�/1/ _ I O� to (AX# ) LE' <br /> CITY ` �/J 11tH N TATE LP <br /> ,114 <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: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <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. p <br /> TYPE OF SERVICE REQUESTED: FbM C MAUG <br /> COMMENTS: AUG <br /> do 20Z1 <br /> J ) INITY <br /> ROUINCOUN <br /> H1s1L171DE��NT <br /> ACCEPTED BY: t/l.rr�f� EMPLOYEE M O DATE: / <br /> ASSIGNED TO: a) EMPLOYEE#: 3� DATE: B <br /> Date Service <br /> Completed <br /> Date already completed): SERVICE CODE: PIE: O <br /> Fee Amount: 'G0 Amount Paid Payment Date B <br /> Payment Type Invoice# —1 Received By: MY <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />