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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER OPERATOR - <br /> V ' 1 0 r )0- �OV <br /> vU CHECK If BILLING ADDRESS <br /> FACILITY NAM a y� l� 1`v y11(a FO <br /> $READDRESS r <br /> Street Number OlrectlonStreet Nama CI I Code <br /> HOME or MAILING ADDRESS (If Diff rent fromSiteSite Address) <br /> v✓.�� /�I V Street Number Street Na.. <br /> CITY Sia CX Ion ST TEt ZIP ' <br /> PHOONOE#j oI ZZ 13 )S ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ,/ CHECK if BILLING ADDRESS <br /> BUSINESS NAME / l) Co / O Go r PHONE# EXT. <br /> HOME Or MAILING ADDRESS lC/ _ / V �•0A 1 � � V FAX# <br /> 1 t1J V`' V ( ) <br /> Cm S .} VY\ S T ZIP C Z IS <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 /> PPLICANT'SSIGNATURE: Vt G+br S 0,tw 7il.-✓ DATE: ' O -11 <br /> PROPERTY/BUSINESS OWNER 0 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> IfAPPL/CANT is not the B/LLYNGPARTY 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/, tient <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at <br /> provided to me or my representative. r <br /> TYPE OF SERVICE REQUESTED: t,r <br /> COMMENTS; <br /> HRONME OUN <br /> HOEP NTAL <br /> ��fNl <br /> N1�bilc. � Consl�ka _� ([�efrn���d ]it') sem., JOS,(/ ) <br /> ACCEPTED BY: 1 ,1 S EMPLOYEE#: r / DATE: O II vI <br /> ASSIGNED TO: V/1` EMPLOYEE M 'j3GPI DATE: 0 <br /> 111 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE; U' 03 <br /> Fee Amount: G2• Amount Paid 't�)2r Payment Date ]()/I 2J <br /> Payment Type 0 <br /> Ail I Invoice# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />