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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> � e <br /> SITE ADDRESS _ N!,pLa ry ^ , � .City �"/�q�--�.4�<T.Z-0 <br /> L Street Number Direction eet Nama JIY Cx7T' CYitU Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) (� <br /> S � 11 Street Number C Street Name — I <br /> CITY STATE zip <br /> PHONE#1 Ex . APN# LAND USE APPLICATION# <br /> gag, S --] �S <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> f� _1 CHECK if BILLING ADDRESS <br /> BUSINESS NAME CJ\ PHONE# Ea , <br /> Zoe S l <br /> HOME or MAILING DRESS FAX# <br /> CITYC <br /> .. 1 S, STATE �- p zip I <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 /> PPLICANT'S SIGNATURE:' DATE: I C) 2- 1 <br /> PROPERTY/Busi NESs OWNER❑ <br /> OP TOR AGER OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANTisnotthe�T <br /> proof of authorization to sign is required Tiil e <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 env e111111ll1lllnta....,,l,,�,,��/s��ite assessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is aVai)a agile time it is <br /> provided to me or my representative. CF <br /> TYPE OF SERVICE REQUESTED: D OCT <br /> COMMENTS: ItnS pec�r rr� JOAQUJJV <br /> WTy L <br /> ACCEPTED a EMPLOYEE DATE: rO <br /> ASSIGNED TO: n '/.' EMPLOYEE#: ppp DATE: <br /> Date Service Completed (if alreadycompleted): SERVICE CODE: I \ 1 Le 1 1.PIEl 0/� <br /> Fee Amount Q U Amount Pai S r D Paymentt Date l�3 <br /> Payment Type Invoice# Check# / Received By: <br /> EHD 48-02-025SIR <br /> SR FORM(Golden Rod) <br /> REVISED 11/17/2003 �,U�, 7 1 ✓ t <br />