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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Coy In GQ alqZC� <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> NvanAm race <br /> SITE ADDRESS q /} NGI,.� waU �`yn luL,ro� �5 Z o 5 <br /> 5 `J greet Number Direetlon V\1 Street Name 1 \V cityZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) J " <br /> Y Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t Exr• APN# LAND USE APPLICATION# <br /> (M ) 3z3 0 8 <br /> PHONE#Z Exr• BOS DISTRICT LOCATION CODE <br /> ( G 1 e -115'31 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> tY \b CHECK If BILLING ADDRESS <br /> BUSINESS NAME Cl PHONE# En. <br /> D om Cake w 3Z3 -o <br /> HOME Or MAILING ADDRESS FAX# <br /> (.R C LY\ I ) <br /> CIN t Y\ STATE CA ZIP 5Z <br /> 15 <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 SIGNATU :/�/r� _ I, %�, DATE: O7.Za31 Z6Z7 <br /> PROPERTY/BUSINESS OWNER L:J ° OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY 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 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. ' r <br /> TYPE OF SERVICE REQUESTED: WO V �/lA VU VIGi Yn <br /> �N <br /> COMMENTS: �AN j � �® <br /> S ENV°"Qu3 <br /> 202? <br /> Ht 7tyRo Cott. <br /> ACCEPTED BY: EMPLOYEE#: DATE: 2_ 2j 22 <br /> ASSIGNEDTO: �I� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: 1�2 _ Amount Paid 5ae� I <br /> Payment Date 31-2 2— <br /> Payment Type Invoice# ' �3 �j�() 3 Received By: � <br /> EHD 25 SR FORM(Golden Rod) <br /> REVISEDSED 11 11/17/2003 <br />