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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST P P- D 5 i i <br /> Type of Business or Property FACILITY ID# SERV CE REQUEST# <br /> ADO 1 cpa� SSU o SERV <br /> OWNER/ OPERATOR <br /> � CHECK If BILLING AODRE$$❑ <br /> rJ L <br /> FACILITY NAME <br /> #JZ -ZLI <br /> SITE Aht)DRESS �t � t t]G to ri Co-- f S� 0S <br /> V Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) / <br /> �t Numher CQ` I '� �h Street Name L <br /> CITY STATE Zip <br /> o doti- <br /> PHONE#1 EXT, <br /> APN# LAND USE APPLICATION# <br /> l20 ) 73 7-,-<2- <br /> PHONE#2 Ex-r. BOS DISTRICT LOCATION CORE <br /> I ) 3-7 3- S 1'5 3 Cie rrrt'�in Cha vtz <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> t" lL CHECK if BILLING ADDRESS <br /> BUSINESS NAIVE V— PHONE# FXJ <br /> C OS 6v (f0 3 r-s3--- 6� <br /> HOME or MAILING ADDRESS ,,.� � f FAx# 1 <br /> CITYIC 7\ n f STATE ll� ^ ZIP <br /> �f7 <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 eharges,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 /> APPLICANT'S SIGNATURE: 6s ellrL &I a V DATE: <br /> PROPERTY/BUSINESS OWNER©— OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If'APPLICANT is not the BxLING PARTY,proof of authorization to sigh 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 ENVIRO.N.iVIENTAL HEALTH DEPARTMENT as soon as it is available end at the same time it is <br /> provided to me or my representative. , <br /> TYPE OF SERVICEREQUESTED: V lef�jrj CiQ( 5 Cel <br /> COMMENTS: Oct q <br /> C 5 znzI <br /> RO UPV COIL <br /> ACCEPTED BY: EMPLOYEE#: Q DATE: <br /> 33 ] O <br /> ASSIGN ED TO: I 1 EMPLOYEE#: lJir I DATE: r <br /> Date Service Completed (if already completed): SERVICE CODE: J P 1 E: <br /> Fee Amount: ' Amount Pai Payment Date r �5 <br /> Payment Type Invoice# Check# Rec'eiV4 By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />