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SAN JOAQUL. —`OUNTY ENVIRONMENTAL HEALTH—:PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 'I I (IO010qlq <br /> OWNER/OPERATOR <br /> C1 ' CHECK If BILLING ADDRESS <br /> 'sFACILITY11NAME <br /> 1 11 <br /> SITEA1DO,RESS f kFi /L�M('��1LIJ•41 Lo17( 9s2� o <br /> �l Street Number rent from <br /> Street Name Cil L Code <br /> NOME Or MAILING ADDRESS (If Different from Site Address) <br /> -1,kKb L_- Street Number Street Name <br /> CITY STATE ZIP <br /> C 20G <br /> PHONE#1 ER. APN# LAND USE APPLICATION# <br /> ()-,)1I _ <br /> PHONE#2 Ex . BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> n ` CHECK if BILLING ADDRESS� <br /> BUSINESS NAME 1'\ N,I` PHONE# E.T. <br /> U WIC OC <br /> HOME or MAILING ADDRESS FAx# <br /> "s n&J-b F>asgS I I <br /> CITY .r/ 6 STATE ZIP T7 Q <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,S TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �� DATE: <br /> PROPERTY/ SINESSOWNER OPERATOR/NLINAGER ❑ OTHERAUTHORIZED AGENT❑ <br /> I PPLICANT is not lrte B/CLING 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 they a time it is <br /> provided to me or my representative. -N <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: � CQf 5 <br /> �g <br /> y£ NUN <br /> DE,4N' rAj <br /> �6V <br /> U/�1 <br /> T� <br /> ACCEPTED BY: Low <br /> o A n \ EMPLOYEE#: DATE: <br /> ASSIGNED TO: V VST VL �✓ EMPLOYEE#: ✓✓✓ DATE: I 15 / <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: IIfo;L <br /> Fee Amount: Amount Paid % Payment Date Z <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />