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SAN JOAQUIN COUN'T'Y ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST 1` <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST If <br /> GcMoM/ --A.1A i Cog S0101c1 <br /> OWNER/ JPERATOR <br /> `J CHECK If BILLING ADDRESS <br /> FACILITYINAME V-IPP S.T0CrTb&J wcoaL 1 3GHOOL . <br /> SITEADDRESS 7y2 r..7 I vPA'-'4S IC VE STOWR)A� ��4 <br /> Streot Numbar Direction Sree ale CI zle Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Sheet Number /Street Namo <br /> CITYQ) STATE ZI64 PW&a '3 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (UN Sri 7—y3 <br /> PHONE EXT. BOS DISTRICT LOCATION CODE <br /> a a- 3a <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. j <br /> HOME or MAILING ADDRESS FAX# j <br /> ( ) 1 <br /> CITY STATE ZIP <br /> J <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of sane, <br /> acknowledge that all site and/or project Specific ENVIRONMENTAL HEALTH DEPARTMENT hourly chat-gas 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 End FED L laws. <br /> APPLICANT'S SIGNATURE: �I ~, DATE: 7/ /ate <br /> PROPERTY/BUSINESS OWNER❑ OPERA•f0 ANAGER l;l4„ HER AUTHORIZED AGENT❑ <br /> IfAPPLICAiNT IS 1101 the BILLING PAR79 proo of aatltorizoflon 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 and at fit me time it is � <br /> provided to me or my representative. Nq�1Y j <br /> TYPE OF SERVICE REQUESTED: CF <br /> COMMENTS: JU <br /> F <br /> MEALS w'ILL$'F DELIV&RM 5\/ A ��iN� �utitp,gtV�°N,og ?�?OTj <br /> 1S IS 711 �tH S ` 0� k,/ IT �qC HOE qR MFNTy <br /> ACCEPTED BY: M EMPLOYEE#: DATE; 12117,t <br /> ASSIGNED TO: EMPLOYEE#: DATE; <br /> Date Service Completed (If already Completed): SERVICECODE: P I E: <br /> Fee Amount: 101_ Amount Palcyp /Sa U6 Payment Date ' 2/ <br /> Payment Type /S� Invoice# Check# IZ t� ecel ed By:aliSt <br /> EHD 45-02.025 SR FORM(Golden Rod) <br /> REVISED IIll 7/2003 <br /> �fazi � s <br />