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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> [FAcuff <br /> ype of Business or property FACILITY ID# SERVICE REQUEST# <br /> Aft FAQ0�35.�5 SR0084� aq <br /> WNER/OPERATOR <br /> CL '� CHECK if BILLING ADDRESS® <br /> NAME Y <br /> $READDRESS <br /> SbMW <br /> Numr city D <br /> ode <br /> HomE or MAILING ADDRESS (N DlReterd from SRO Add ross Ado L e- �yl e <br /> C" sweet Numlxt W <br /> -rR c s"'C a 5 376 <br /> PxoNE#1 �*• APN# LAND USE APPUCATION# <br /> 1 ) <br /> PHONE#2 BIDS DISTRICT LOCATION CODE <br /> 1 ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> S PHONE# <br /> BustNEss NAME 4 q /- a Ext. <br /> Hoerr or MmuNG ADDRESS e deco - `� FAIL# <br /> ( ) <br /> CRY STATE CA <br /> ,f LP /,S <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, opeeraat'or or authorize[ d agent of some, <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 /> 1 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��RRyE: �l-�� �(/�� DATE: Q J- 13 - p�9. <br /> PROPERTY/Busiress OwNERW TOPERATOR/MANAGF.R ❑ OTHER AUTHORiZEDAGFM❑ <br /> 1fAPPL1GNT is not theBILL1NG PARTY.proofojauthorizadon 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 environmentaUsite 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. P <br /> TYPE of SERVICE RwuesTED: Cv.j(\e f C h Ffr` <br /> Cowunts: <br /> JAN 14 1022 <br /> SAN,'0A <br /> QUIN <br /> I 11EgLTH pE gRTOENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> AsstGNm To: a EMPLOYEE#: DATE: <br /> Date Service Completed (if atreadycompleted): SERVICECODE: PIE <br /> Fee Amount: ,S�_ Amount Paid O y� Payment Date V1 41-2 2 <br /> Payment Type `sem, invoice# Check# vZ Received By: <br /> EHDSED 11/1712D03 <br /> 1/5 I S <br /> REVISED 11117/2003tt1""' ���///"' SR FORM(Gilden Rod) <br />