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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST "RIS y72 d <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> O)Fr- 11 :5ROVE 419 8 <br /> OWNER( OPERATOR <br /> `v t, 11 1 �Awpzits <br /> 1. CHECK If BILLING AODRES <br /> FACILITY NAME <br /> SITEADDZ S ��� T SWf�1�'C <br /> Street Numher Direction Street Name CI D Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SU�� vzve. Street Number Street Name t <br /> CITYV. J„ J_�t STATE zip <br /> PHHOONE#1#1 �J(D ExT. APN# LAND USE APPLICATION# <br /> ` (, Y 1 <br /> P ONE#2 Etr. BOS DISTRICT LOCATION CODE <br /> �u�i) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ' V 1cAgu\-LzItS <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME1 r0"l ^_ �^ �� I �.I �� PHONE ?T• <br /> HOME Or MAILING ADDRESS 'A%# ) <br /> CITY STATE641 zip q S2I _ —/ <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> APPLICANT'S SIGNATURE: I/1\1 DATE: <br /> PROPERTY/BUSINESS OWNER44' OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> lfAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. ", <br /> TYPE OF SERVICE REQUESTED: vD r'71n 1,T�T'O R NT <br /> COMMENTS: —4 VIED <br /> WT O,� G01,11 M"1 C,mM V.l 0S-alf-'� SAtl � 12021 <br /> JOAENWROUINDDAfEiVrU ly <br /> MFq�TyDe'; 7ALVT <br /> ACCEPTED BY: EMPLOYEE#: 0-1 SS DATE: (O, l- Z <br /> ASSIGNED TO: Mil EMPLOYEE#: O -5 it DATE: ,,0 . 1 - `L( <br /> Date Service Completed (if already completed): SERVICE CODE: U PIE: kv 0 Z <br /> Fee Amount: t 5 2, U-o Amount Paid It—a Payment Date IOLI 21 <br /> Payment Type Invoice# Check# /zo Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 JC ' <br />