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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Prop rty FACILITY ID# SERVICE REQUEST# <br /> SM01 �-1 <br /> OWNER/OPERATOR <br /> tc� I(•7 ,. / CHECK If BI LIN ADORE <br /> FACILITY NAME it e (t f� �K!v/�� L� ✓�� Ai <br /> ^ E rs <br /> SITE ADDRESS Cl IAV I 47�f.( ct% r,rv�/ .N''l <br /> 7 <br /> I Street Number I Direction �# �' '-'-Street Name Cit ZI Cotla <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Nam <br /> CITYt+ < STATE ` / ZIP ���J <br /> PHONE#1 Ex' APN# LAND USE APPLICATION# <br /> PHONE En. BOB DISTRICT LOCATION CODE <br /> ( 1 (J <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �}n'a\\(� ����1^" � CHECK If BILLING ADDRESS <br /> BUSINESS NAMIE`\ Y tl. 4 ''`QQ�S PHONF, Lou0 E' . <br /> n ` W ` lV V <br /> HOME or MAILING ADDRESS ruts FAX# <br /> V\ I ( ) <br /> CITY STATE ZIP q 3 <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 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 tbe performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,Si and 'l; LriA.L 1 J <br /> APPLICANT'S SIGNATURE: 1 DATE: <br /> PROPERTY/BUSINESS OWNER 13 OP R/ ANAGER OTHER AUTHORIZED AGENT <br /> ffAPPL/CNT is not the NG PARTY proo of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 same time it Is <br /> provided to me or my representative. P <br /> TYPE OF SERVICE REQUESTED: O � F ccNr <br /> COMMENTS: � i� <br /> Oct((. 3 <br /> yDEPgRTTq� rY <br /> MZ T <br /> ACCEPTED BY: EMPLOYEE#: DATE: '1 1 <br /> ASSIGNED TO: EMPLOYEE#: DATE: 1 <br /> Date Service Completed (if already completed): SERVICE CODE: I P 1 E:i �Z <br /> Fee Amount: 021LS G Amount Pa' �S�.d V Payment Date ..3 <br /> Payment Type � rj� Invoice# Check# /!S 1101 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> Q �,05�08�3 <br />