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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> DuUr�� Std wL619 <br /> OWNER/ OPERATOR I1 ^� <br /> Rt\ I q q u Ors In � , CHECK if BILLING ADDRESS <br /> FACILITY NAME --Fown p lam/ . L4 n f ,5uay <br /> SITE ADDRESS /3 '-f 95 6` ICJ �) l.(W '� I�� LoO e'fd CA �� d37 <br /> Street Number Direction Street Name C ll� Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SI* VIC Street Number Street Name <br /> CITY Q STATE�fi ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> ( .5'o) So I - ogH `9 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR R <br /> Up ltd'V r KLX.( Y CHECK if BILLING ADDRESS <br /> BUSINESS NAMEuO-fs PHONE# Elm( <br /> RIt 1i9 zrc o S o9 � y <br /> HOME or MAILING ADDRESS FAX# <br /> I HB9 ) <br /> CITY LO CEZJ�D STATE ZIP r �7 <br /> BILLING ACKNOWLE GEMENT: 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?91= <br /> s. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER O OTHER AUTHORIZED AGENT O <br /> IfAPPLICANT is not theBILLIIyG 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 JoAQUtN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at 10 e time it i5 <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: `�V V'`�SL.�L� ��_ �y <br /> COMMENTS: jn n (gyp 1 ? 9 <br /> G 4` l� ��12 w� yZAiv,pFpgR[N �� <br /> `J' , rM�rT <br /> ACCEPTED BY: Ii EMPLOYEE#: DATE: i 2 <br /> ASSIGNED T : I LI EMPLOYEE#: 2 5- DATE: <br /> Date Service Completed (if alrea'd'y completed): SERVICE CODE: D 40 P 1 E: <br /> Fee Amount: +I C5z Amount Paid �l� i Payment Date 111-22-1Z1 I -TZ Z <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />