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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> F-A 00 220 S2 C0$`I3ZD <br /> OWNER I OPERATOR <br /> 1f 2ex Z CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> COS 20. v1 C <br /> SITE ADDRESS Y �^ q1C <br /> Street Number Direction o dttree Na�mO V�O1p ede <br /> �O <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> l LiI25 Dr-et? C I Street Number Street Name <br /> CITY STATE ZIP <br /> 5 }oC ot7 C, 4 O <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> 112(59) - a28 1 <br /> PHONE#2 EX. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ' <br /> 5 cO ^ ' CHECK If BILLING ADDRESS <br /> BUSINESS NAMEV LL PHONE# ExT• <br /> \L C - \A/ 3+(5cr O CA 1 (263) � D <br /> HOME or MAILING ADDRESS FAX# <br /> CITY s 16 CY O STA zip S. , <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,STATE and FEDERAL laws. <br /> -v <br /> APPLICANT'S SIGNATURE: ) P_V1 7 i N Gh o -IQ �' 7 DATE: lo - a - 2 I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTRER AUTHORIZED AGENT IJ <br /> fAPPLICANT 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 smote time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: �� �G `�'� P 6V\- IC� <br /> COMMENTS: <br /> q OCT <br /> `S'9LV JOA <br /> h Jy�ENAR M L <br /> II- <br /> ACCEPTED BY: r 1/1 fN ill' EMPLOYEE#: DATE: <br /> ASSIGNEDTO: tvVyEMPLOYEE#: DATE: <br /> Date Service C-onnipleted (if already completed): SERVICE CODE: 00 P1 E: I to 03 <br /> Fee Amount: Z. Amount Paid IS;2,DD Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02.025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />