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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 /> CHECK if BILLING ADDRESS <br /> FACILITY NAME 1 � M <br /> SITE ADDRESS C (n� s.4-O� -I_O'] �jzOL• <br /> 'L(( <br /> _ Street Number I Dlreetlon J H 0'tStreat Name C city ZID Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> LI I � I= Cr ; Street Number Sire¢t Name <br /> CITYSTATE ZIP <br /> Y e.v C J'G yr A- Z 3 <br /> PHONE#'I Ezr• AP # LAND USE APPLICATION# <br /> (sty) ';} S '7,3 <br /> PHONE#2 Eu. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQU R <br /> REQUESTOR <br /> CHECK If BILLING <br /> BUSINESS NAME PHONE# H" <br /> HOME or MAILING ADDRESS FAx# J 744 <br /> CITY STATE ZIP Eq��RON,M COON <br /> BILLING ACKNOWLEDGE T: I, the undersigned property or business owner, operator or authorized agent �tr , <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 b performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATu'add FEDERAL.laws. <br /> APPLICANT'S SIGNATURE: l�ro J�JG1. DATE: I I Z I Z L <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER �% OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT 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. <br /> TYPE OF SERVICE REQUESTED: )"QQ C V ey-I is .QKsgfc <br /> COMMENTS: <br /> ACCEPTED BY: • I v t't�VL.�V1 JEMPLOYEE#: DATE: <br /> ASSIGNEDTO: qf, EMPLOYEE#: DATE: <br /> Date <br /> --- <br /> Date Service Co plated (If already completed): SERVICE CODE: <br /> Fee Amount: (C)2 Amount Pal [�� Z)D Payment Date 2 ZZ <br /> Payment Type Invoice# Check# 77 1 <br /> Rece ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />