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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY In# C SERVICE REQUEST# <br /> v <br /> OWNER/OPERATOR <br /> A AA ; Y D e, /~AfA M,t CSA OV I�- CHECK if BILLING ADDRESS❑ <br /> FACILITY DAME 22S 6k'v- LJ <br /> SITEADDRESSl V ZU t� LCA`In 41' <br /> Street Number Directlon Street Name CityZI Code <br /> H or AILING DDREs (if Differen Site ddressl <br /> y �or1� v � <br /> Street Number Street Name <br /> STATE Zip <br /> HONE#1 (` ExT- APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CORE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> rV a� f/VZya 5y/1 N� CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME1 .J [J� C PHONEXT. <br /> can&—r-H or, t ADDRESS LI Fax# <br /> ChI ` ( 1 <br /> ITY / STATE ZIP <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 rile 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: E,4M 1'r0 rt'o SA tJ 11,Wi DATE: <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is not theBlLLING 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 environmenE�to assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and a�[119*11e it is <br /> provided to Inc or my representative. �+N <br /> TYPE OF SERVICE REQUESTED: ft 4® <br /> COMMENTS: <br /> 0. Q�,� ?�?j <br /> FNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED To: V . W l EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P J E:\q 0'-_7 <br /> Fee Amount: r— Amount Pa' `� Payment Date -� I <br /> Payment Typ Invoice# Check# Received 6 y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />