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� (L, S3 -792 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> POV-WD S� 0 <br /> OWNER/OPERATORQ ^ <br /> N )t� rR ��r 1 IBJ CHECK If BILLINGADDRESS® <br /> FACILITY NAME 't.. �' _ q/ 1/,. �— t f ✓" <br /> r 1zrL1 �6T�✓Ct1IO✓Z /! e COLI e- <br /> SITE ADDRESS Ptz g4 6��' /�l$Z y <br /> Street Number Dlrectlon Street Name CI X21 Code <br /> HOME or MAI G ADDRESS (If Different from Site Address) <br /> 1/-/©O D Street Number Street Name <br /> CITY r C STATE ZIP 9SZy L <br /> PHONE#1EaT• APN# LAND USE APPLICATION# <br /> (gog ) Xt6 _C)668 <br /> PHONE#2 ExT BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPH <br /> r # Exr. <br /> C'OS7-4 S !'t 1, PST" A-e C yoc1 o —o6a g <br /> HOME or MAILING ADDRESS/gyp / FAX# <br /> %/ ear 4Jm0A Cdr 1 1 <br /> CITY ,/; STATE < zip qS'ZY Z <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 that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE d DE"^(ry/-`/��aws. _ <br /> APPLICANT'S SIGNATURE: �� DATE: — M - ZI <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> I,f APPL/CANT is not the BILLING PART}'Proof of authorization t0 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at tj IRI it is <br /> provided to the or my representative, pJA <br /> TYPE OF SERVICE REQUESTED: <br /> ciA <br /> COMMENTS: AVU 1 <br /> rkO C���1 ! NV p tot COON <br /> SA1AL <br /> E�RONME TM T <br /> HEp,�-(H DEPA <br /> ACCEPTED BY: 1� S . EMPLOYEE#: DATE: 1% <br /> ASSIGNED TO: 1 ,� EMPLOYEE#: ,( DATE: I /y <br /> Date Service Completed (if already Completed): SERVICE CODE: <br /> Fee Amount: 1; •C/ Amount Paid �5 2 Payment Date C '2/ -Z <br /> Payment Type Invoice# Chec # ` .p ?p�'S �j Received By: <br /> EHD 48-02.025 - SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />