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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT n SLi b9 02 <br /> SERVICE REQUEST I� <br /> Type of Business or Property /FACILITY ID# � �SEORVOICE REQUEST# <br /> OER/OPERATOR J \f BIL 2 <br /> (] � CHECK if BILLING ADDRESS <br /> NS <br /> FACILITY NAME -P co s 2 + e <br /> SITE ADDRESS i-� I'1 S I / n 1�� <br /> Street Number Direction VL Street Name Cit Zip Code <br /> HOME or MAILINGADDRESS (If Different from Site Address) �� <br /> (37 `� - 11 212 11 ' � §,reef Number Street Name <br /> CITY 1 � } STATE (/M ZIP CT5 Z <br /> P NE 1 \ Ezi APN# LAND USEAPPLICATION# V` <br /> PHONE#2 Em BOS DISTRICT LOCATION CODE <br /> t l <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR n rnAA V -/ /T� J..� I I <br /> .('f)' (�(, l I , t CHECK If BILLING ADDRESS <br /> BUSINESS NAME —�J� /' hS � 1 `/i _ I PHO(J Il� II^ , r I Ezr. <br /> HOME or MAILING ADDRESS l/ V r\,f FAX# V ^r`-'t <br /> f 3 3 S Col 2t0 I( ( ) <br /> CITY STATE cvn� ZIP -,7—e)2 t C <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 SIGNATURE: YqQral f}tti cd? 110 DATE: 1/3 <br /> I 2 <br /> PROPERTY/BUSINESS OWNER❑ 'OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> If APPLICANTISnolthe BILLINGPARTY 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 t0 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: <br /> COMMENTS: (�1. .,'zA n� 8� �,`/IW II� I•Eb Iv'A�/�VI'W Uv� � OUYI3CAZ�TZ'� QAIC�UuNr�IY F O <br /> ACCEPTED BY: '� EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICECODE: �l/f PIE: n 2, <br /> Fee Amount:41 GJZ Amount Paid «a Payment Date 2 13'22 w <br /> Payment Type l Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />