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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> a Type of Business or Property FACILITY ID# ,�ERVICE REQUEST# <br /> OWNER/OPERATOR U��y:JUI�d1'0�J <br /> 1 CHECK If BILLING ADDRESS O <br /> FACILITY NAME (.p�/Anf/JG q 'Q..,�(� — (Lo <br /> SITE ADDRESS IJ�JC{GJ(,woo l(J � �' ����� <br /> Street Number DlrecHon Street Neme CI ZipCotle <br /> HOME or MAILING ADDRESS <br /> (If Different from Site Address) <br /> ( > Street Number Street Name .yN <br /> CITY dA`�'C� STATE C 4- <br /> LP �--b 2 <br /> P ONE 91 Exr. APN# LAND USE APPPLLIICATION# <br /> PHONE#2T BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR � N r o T V,` too <br /> 1VN <br /> WtC.� U CNECKifBILLING ADDRE55O <br /> BUSINESS NAME PHONE# E'c' <br /> HOME or MAILING ADDRESSI C. <br /> CC" • I 'A%# ) <br /> F'f(iu/tA/L�r CI_ •� _ STATE LP <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 T,I❑�d that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards a d 1•EDERAL la s� / ,n ']/,A�/' <br /> APPLICANT'S SIGNATURE: �V lr' ' DATE: Y 36'O t)V 1 <br /> PROPERTY/BUSINESS OWNER[�`f� ERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 1 (f <br /> ; <br /> ' ?/0�C IOL� N <br /> /y, INP, <br /> O <br /> MFN0UN <br /> Y <br /> ACCEPTED BY: < uC 1V- -. jfEMPLOYEEM DATE: — <br /> AsSIGNEOTO: 7R .Vvl� EMPLOYEE#: ATE: — Z/ <br /> Date Service Completed (if already completed): SERVICE CODE: �9 7, PIE: IC,00( <br /> Fee Amount: -16�> , — Amount Pal ,v(� Payment Date y( H <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />