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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEE ARTMENT <br />SF,RVICE REQUEST <br />TVDe of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />�^ -3,3 11 � <br />`� <br />[tM�EO:rMAIUNG ADDRESS 4� <br />zs <br />VOWROPERATOR <br />- <br />CHECK If BILLING ADDRESS❑ <br />FACILnY NAME o <br />COMMENTS: <br />SITE ADDrREB <br />Oa, "7 l <br />SWfreet Nema <br />2i Cotle <br />mer Dtrection <br />S NMENTAL <br />HQ or ILING ADDRESS (If Different from Site Address) , <br />l•.li�t1 ,/ill Street Number <br />Street Name <br />CITY <br />$Tp¢ <br />(� <br />ZIP <br />•LAND <br />EMPLOYEE M ;r <br />' /E'n• <br />PHON1 <br />(� L <br />ASSIGNEDTO: <br />APN# USE APPLICATION # <br />Z — <br />PHCNE RL a' <br />SOS DISTRICT <br />II OC TIO COOE� <br />d-nlvTU A rTnR / CFRvwv, REQUESTOR <br />REQUESTOR �yvl L�^ I,t.{�,/'In .I AA(-- <br />IAJ1 v1 I V•a <br />W 1A <br />CHECK If BILLING ADDRESSE1 <br />PJ <br />fj� - <br />BUSINESS NAME /111 <br />�^ -3,3 11 � <br />`� <br />[tM�EO:rMAIUNG ADDRESS 4� <br />FAg%tq�Ik <br />9K['' MQ4 <br />8 <br />CITY STATE CA <br />ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, uporarUI U1.or— <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 ap ication a that the work to be performed will be done in accordance with all SAN JOAQUiN <br />COUNTY Ordinance Codes, Standards, S TE and FE laws. (/,/�I <br />APPLICANT'S SIGNA DATE: v�I <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BILLfNG PARTY. proof of authorization to sign is require 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 environmentallsite assessment <br />ir:fC•^ :Clic^ t0 Gtle s .?,t JOprlr1LN CpLMTY ENVIRONMENTAL )-?EALTH DEPARTMENT as SOOn as It is available and at the �rllCOr it i5 <br />:.,e PAS 1,. fv-.o <br />provtucu to nue or u0 repres............. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />S NMENTAL <br />SNR <br />9EPM� <br />NFJd-TH <br />ACCEPTED BY: <br />EMPLOYEE M ;r <br />DATE: <br />12 It, <br />ASSIGNEDTO: <br />EMPLOYEE#: ,( <br />6 <br />DATE: <br />Date Service ComplMali—ready): <br />SE2VICECODE: <br />P1E:Fee <br />Amount:Amount <br />Paid <br />2 �a <br />Payment Date <br />� 30 O1. <br />PaymentType <br />Check # 0�� <br />Received By: �L <br />EHD 48-02-025 SR FORM (Golden Red) <br />REVISED 11/17/2003 , <br />