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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQdUEST# <br /> dal � c a" 10 D12- <br /> OWNER/OP RATOR <br /> 0 ,I�`` CHECK if BILLING ADDRESS <br /> FACILITY NAME Y tt� A`'A„�a �- <br /> SITE ADDRESS 1�/JJ.V�r�V�,"4 'wrW �a <br /> "etr e4 t Norr Direction O Street Name Cll Coca <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY 5kAA f' STATE zip <br /> PHONE#1 J'� E" , APN# LAND USE APPLICATION# <br /> PHONE#2 ExT BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ' - kj N <br /> �.!)a�' 1 CHECK If BILLING ADDRESS <br /> BUSINESS NAMEG.,_ PHONE# - Ea <br /> HOMEOr MAILINGDD SS t„lF� FAX# <br /> CITY STATE zip'Ill'Zt f D — V JS <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific EN NMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as ' ent' led on this form. <br /> I also certify that I have prepared this applic ton an that the work t0 be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ST DERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> I <br /> PROPERTY/BUSINESS OWNER❑ VLIPAR <br /> /MANAGER OTHER AUTHORIZED AGENT Ip <br /> IJAPPLlCANT is not the TYproofofauthorization to sign is required line <br /> AUTHORIZATION TO RELEASEATION: 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available athe same time it is <br /> 11�at <br /> provided to me or my representative. y <br /> NIE <br /> TYPE OF SERVICE REQUESTED: �,,�/ CES <br /> COMMENTS: O� OGfJ/ver S 'L� /J IU3 <br /> /��Q�/✓ aN zozz <br /> S�1 j� C H EIyVIR NME DUIV <br /> V ��vEP,gR>M NT <br /> ACCEPTED BY: S EMPLOYEE#: /, DATE: 3 <br /> ASSIGNED TO: EMPLOYEE#: V DATE: <br /> Date Service Completed (if already completel): SERVICE CODE: 01E: I L101 <br /> Fee Amount: a' Amount Pal /�� Payment Date 3 2Z <br /> r <br /> Payment Type Invoice# Check# 13�&OZ 2 Received By: <br /> EHD 48-02.025 SR FORM(Golden Rad) <br /> REVISED 11/17/2003 <br /> {�LIl�2a�5 S' <br />