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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> A 000'7VD(D SIR X81l95 <br /> OWNER/OPERATOR <br /> oYn cw-)p_` ( CHECK If BILLING <br /> T � <br /> FACILITY NAME V 1V G`" <br /> "�ovnyn I F <br /> SITE ADDRESSI 1'11C1FkC}- A V CC -T C, C-e—TO <br /> t mb r Direction v t U VF- t"8T( at Name CI Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 6l Zl-I <br /> Street Numaer l..l�I 6 strleet Name <br /> CITY �O 1 w / STAC P ZIP 01S 2 <br /> PHONE#1 C' tv Exr. APN# LAND USE APPLICATION# <br /> noq ) ` gf3 -5gy5 <br /> PHONIER Ev. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR" <br /> CHECK If BILLING ADORES <br /> BUSINESS NAME PHONE# EXT. <br /> � omyrgIs CIA c 20 Zi E3 <br /> HOME or MAILING ADDRESS FAx# <br /> -`�FLiOPp' e- Ave ( ) <br /> CITY- S—) Out--bN STATECp ZIP q CD 2O <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, STA ERAL laws. <br /> APPLICANT'S SIGNATURE: �� DATE: ` 102 202 <br /> PROPERTY/BUSINESS OWNER❑ OPERA't ZVANAGER 0 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 aL(he same time it is <br /> provided to me or my representative. 14 <br /> TYPE OF SERVICE REQUESTED: C `�r la✓Vb CE` <br /> COMMENTS: <br /> �� u vJv�rcg1 tet,, 2o2r <br /> (ft gMEry,04J y <br /> ACCEPTEDBY: ') EMPLOYEE DATE: 1Z ry ZI <br /> ASSIGNED TO: EMPLOYEE#: DATE: �C <br /> Date Service Completed (If already Completed): SERVICE CODE: PIE: <br /> Fee Amount: _ Amount Paid `ya Payment Date 212 2/ <br /> Payment Type Invoice# '4I Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> ?� 1�6 JZg <br />