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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST PR d l/OD -/ 9 <br /> Type of Business or Property FACILITY 1D# ERVICE RE¢U ST# <br /> TA bDVZU) f1W5 <br /> OWNER/OPERATOR lL I u CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME N <br /> SITE ADDRESS ,n O 1W <br /> Street Number Direction Street Name Cit ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> jVS� v� Street Number Street Name <br /> CIN ` e tLx I,C STATE CA <br /> ZIP 0111, <br /> PHONE#1 EM• APN# LAND USE APPLICATION# <br /> rwo') I I�s rt' <br /> PHONE#2 Ezr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR O�t ` t� t <br /> t/N,J I11-`5 I U CHECK If BILLING ADDRESS <br /> PHONE# <br /> BUSINESS NAME � r� � Sv `OL nV1AA' (2127 1�y ,4rf, I E <br /> HOME Or MAILING ADDRESS (O la7 ,rt _ l j, i� ujol FAJ(# <br /> CITY tl w i _ ✓6 y P-k STATECA ZIP QF l l <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, S TE. d FEDERAL laws. II <br /> APPLICANT'S SIGNATURE: c DATE: (�(Z 6 I Z I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ ' <br /> If APPLICANT 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 andtime it is <br /> provided to me or my representative. ►r <br /> TYPE OF SERVICE REQUESTED: Todd ` 41164 D <br /> COMMENTS: % 202 <br /> U V t W �- -1?? cou <br /> Nry <br /> D0i;;zNT <br /> ACCEPTED BY: IA.- EMPLOYEE#: g�n <br /> ASSIGNED TO: EMPLOYEE#:Date Service Completed (ifalready completed): SERVICE CODE: Z <br /> Fee Amount: �Z� Amount Paid a r Payment Date 1012 CQI2( <br /> Payment Type CQ� h Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />