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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Uu�� �Iy S�bu u52 <br /> OWNER/OP RATOR /�,V,t1 1� j1 <br /> 1 •tOve �//QI Ir1GS CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> ncl m U oi» <br /> SITE ADDRESSI )r-. o j cY S-3SV <br /> J2 11 Stem StreNumber Direction 2 e S rest Nama5�Yi P /_" Cit Zi Coda <br /> HOME or MAILING ADDRESS (If Different from Sit e Address) � <br /> Q S r~• iN Y /201 _t'� Street Number Street Name <br /> CITY d^ Us,1-e C ct STATE 60 <br /> ZIP q S 33K'PHONE#1 ` EXT• APN# LAND USE APPLICATION# <br /> (g^ .25936802 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ' / / <br /> 1 el • �� /t I (h✓e7 �/ u l Jo {tet C S CHECK If BILLING ADDRESS <br /> BUSINESS NAME Sae) (,�1hnC4 LI / HONE# EXT' <br /> J /7 n'7('7 ( uH l® 28q36'92 <br /> ¢i <br /> HOME Or MAILING ADDRESS I FAX# <br /> CITY ,A/1 u� e G STATE /•u ZIP v S.3.3 il <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 FADE laws. <br /> APPLICANT'S SIGNATURET (/. DATE:X <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> I,fAPPLICANT 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 and at the saltie time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: -r-0 <br /> COMMENTS: -Ld <br /> SAN JOAQUIN COUNTY <br /> ENWRONVENTAL <br /> HEALTH D'_-?A.T(r,MEN T <br /> ACCEPTED BY: EMPLOYEE#: 0 DATE: f I 2 2/ <br /> ASSIGNED TO: 62 1/ ,{ EMPLOYEE#: DATE: I I 2 Z/ <br /> Date Service Completed (if already completed): SERVICE CODE: O I P I v <br /> Fee Amount: 19 2- Amount Paid G�2- ._ Payment Date C� Z <br /> Payment Type �, Invoice# C # 3� bo Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 12b S�'S7 g� <br />