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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property � FACILITY ID# ��ERVICE REQUEST# <br /> ii a <br /> 60 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> oO <br /> FACILITY NAME �j� z,ay <br /> SITE ADDRESS4. � �l Y U Np Co, l t <br /> Street Number Ditrection Slreat Name CI Zip Code J <br /> HOME or MAILING ADDRESS (If Different fr m Site dd ess) <br /> � '� <br /> Street Number Street Name <br /> CITY �/ STATE ZIP Z� <br /> PHONE#1 �Q Ems• APN# LAND DSE APPLICATIQN# <br /> ( 40� o q8 <br /> PHONE#2 Ezr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR /7 �� �m^ <br /> ( i v , C CHECK if BILLING ADDRESS <br /> BUSINESS NAME4 G© Lt <br /> PHn 61 <br /> N <br /> HOME or MAILING ADDRESS �. FAX# <br /> 110 2 01 AaLk X ( ) <br /> CITY STATE clog ZIP cr'9 6�� <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,STATE and FEDERAL,laws. <br /> APPLICANT'S SIGNATU� DATE: /l <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> /fAPramT is not the BlcciNG P_anrY 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 and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: y <br /> COMMENTS: <br /> . <br /> NAV <br /> d / Z421 <br /> 33093 � rGM�yE4CTyDEUMfNTUNiI <br /> ACCEPTED BY: t EMPLOYEE M ry� DATE: I I A7 I <br /> ASSIGNEDTO: EMPLOYEE#: V DATE: 1 �1 <br /> Date Service Completed (if already completed): SERVICE CODE: ' P, <br /> Fee Amount: Amount Paid I�a Payment Date <br /> Payment Type Ca Invoice# 3!18�U Cj3 Received By: <br /> EHD 48-02-025 Q SR FORM(Golden Rod) <br /> REVISED 11/17/2003 �R6�1✓�� S <br />