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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE RIE'QUErST�Q�Yn# <br /> �K ���'l� " I <br /> OWNER OPERATOR <br /> C16 <br /> CHECK If BILLING ADDRESS <br /> / <br /> FA ITY NAME <br /> SITE ADDRESS ((//''UU <br /> 23kraetI ber Dire n / 'St at Name �CI ZI � <br /> HOME or MAILING ADtlDRESS (If Different from Site Address) <br /> Number Street et Name <br /> � CffV $TATE ZIP <br /> Y C9J3 26 <br /> PHONE#i Ez . APN# LAND USE APPLICATION# <br /> PHONE#2 EZT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REOUESTOR <br /> f f CHECK if BILLING ADDRESS <br /> BUSINESS NAME I C ,^! PHONE Ems• <br /> tb/HOME Or MAILING ADD ESS ' I/ FAX##19 C? A <br /> ( ) <br /> CRY y6,C1 STATE CA ZIP S <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: LcYn-21 ul Ys - DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPu ERATOR/MANAGERT3 OTHER AUTHORIZED AGENT <br /> If APPL/CANTisnotthe BlLL1NGPARTY proof 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 1 at the same time it is <br /> provided to the or my representative. Y <br /> TYPE OF SERVICE REQUESTED: FA <br /> COMMENTS: <br /> c �970 <br /> �JOga 2� <br /> 11FAC-rly�f M NP 1y <br /> ACCEPTED BY: MPLOYEE#: DATE: ,21 <br /> ASSIGNED TO: EMPLOYEE#: DATE: 1 <br /> Date Service Co pleted (if already completed): SERVICE CODE: OW PIE: O- <br /> Fee AmouOdlI Amount Pai S�.U� Payment Date Z <br /> Payment Type Invoice# Check# Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> ft-W413'111 S <br />