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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST P 2 0514 0 91 y <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SD '-'D (ESS C cea I tr I Lm (\� V�t Zo'3 <br /> ,l v Street Number DlrecdoJn `�" Street Name `�� C 'lZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 1 Street Number Street Name <br /> CITY STATE ZIP <br /> a C /� <br /> PHONE#t Exr• APN# LAND USE APPLICATION If <br /> l 2Lq 0-0i � <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> (• 01) —i $ <br /> CONTRACTOR SERYWX REUESTOR <br /> REQUESTOR <br /> CNECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EKT• <br /> HOME or MAILING ADDRESS FAx# <br /> t ( ) <br /> CITY S _ Sm ZIP <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 farm. <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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: Al bCf J0 2c[y rk- DATE: �(�I� 12,I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHERAUTHORIZEDAGENT❑ <br /> IfAPPLfCANT is not the BILL/NG 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. ,,11^^ p <br /> TYPE OF SERVICE REQUESTED: IAK'u OIISVt'' 1M ' FC <br /> COMMENTS: <br /> SAN JO A U/N CO <br /> P 2021 <br /> L G Q/Un�/ / yAC <br /> FTy pE�M NT <br /> ACCEPTED Y: L II S EMPLOYEE#: V DATE: 10 /7 <br /> �I <br /> ASSIGNED TO: ILA t( EMPLOYEE#: 33Lv DATE: ) -71 1.4- 1 <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: I 0 <br /> Fee Amount: I 2 ' Amount Paid5a r Payment Date V 21 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 45-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />