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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILI ID# SERVICE REQUEST# <br /> 1A91 I'a- d "a Y, <br /> OWNER/OPENTOR. <br /> Jit), <br /> ��(t m�1,1v1,i Zf 1�J �� '�j0)9ar-� CHECK If BILLINGA00RE33� <br /> FACILITY NAME <br /> C rl i <br /> SITE ADDRESS �/JIDII <br /> treat Number Dlr¢etlon (� Street Name • L Code <br /> HOME or MAILING ADDRESS (If Different from Siteddress) IAf1 �{�,�y� �{Cy� r� <br /> Street Number V v —� Stred t/Name <br /> CITY I UY l S ATE <br /> .j <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> r2 tit 161-'3,q <br /> PHONE#2 Es*• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR � <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME !I na It-ce N ( I PHONE <br /> C� ExT <br /> `d2 3 �( <br /> HOME or MAIN``D 1 ESS Y (A%# ) <br /> CITY ,` I -bI— ' ` ZI" ( Z <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of some, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with thisproject <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 /FE�JDERRA laws. <br /> APPLICANT'S SIGNATURE: !�,S//!I DATE: ltLi ' a <br /> e <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is riot the BiLLrNG PARTIproof 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> bY-k J-e �v� ESE Alp <br /> wC l uo to l 6 �Zl <br /> H fN"YOUlNCo N <br /> ACCEPTED BY: EMPLOYEE#: q DATE: U <br /> '9RTry NT <br /> ASSIGNED TO: rA.1- EMPLOYEE#: Z DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ' PIE: 4' P3 <br /> Fee Amoun : y Amount Paid �a Payment Date U I <br /> Payment Type C Invoice# #. Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> P R05376W S <br />