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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# \ SERVICE REQUEST# <br /> n2vJ �Q OQD_' <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> ii: �c, e y,' <br /> FACILITY NA <br /> rin I {6r��y�-�'S�in C. �oc• LL / / <br /> SITE ADD7RES P''Of' llarlah <br /> G t S^trreett Number Direction Street Name C / ZipCode <br /> i t <br /> HOME Or MAILING ADDRESS (If Different from Site Address) r) S, �4r•�'� Tr�� led <br /> `� Street Number Street Name <br /> CITY J STATE ZIP 5—3 <br /> PHONE#1 rf-('ll Ex . APN# LAND USE APPLICATION# <br /> ( 2o?) &I.? Cho '? 2 <br /> PHONIER Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR / l n / <br /> L /r ✓ '4 r CHECK if BILLING ADDRESS <br /> BUSINESS NAME ///��' PHONE# Ex . <br /> HOME Or MAILINGADDRESS ` q FAX# <br /> 0'?� <br /> CITY des S T ZIP S-3 <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 entified on this form. <br /> I also certify that 1 have prepared this ap 'catic and at the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Coder,Standard. TAT EDE L laws. <br /> APPLICANT'S SIGNATURE• DATE: ?-/a—Z Z <br /> ROPERTY/BUSINESS OWNER ERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> lfAPPLICA is no eBIGGING PAR7-}'proof of authoriZatioe to sign is required Title <br /> AUTHORTZATION T RE ASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, heeby uthorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN QUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the same time it is <br /> provided to me or my representative. I _A A <br /> fp <br /> TYPE OF SERVICE REQUESTED: 0d V•Q�'�.(CLP CV�-�A4;rL vim- C <br /> COMMENTS: <br /> Mph, �0 <br /> ACCEPTED BY: (;�� EMPLOYEE#: DATE: <br /> AsSIGNEDTO: I/V EMPLOYEE#: DATE: <br /> Date Service Completed (if already co pleted): ��v SERVICE CODE: No o P 1 E: <br /> Fee Amount: -)k l5 Z� 1 <br /> Amount Paid Payment Date A 10 Z Z <br /> Payment Type Invoice# 40'Zb'5Q(Li Received By: <br /> EHD 48-02-025e A r A SR FORM(Golden Rod) <br /> REVISED 11/17/2003 °� /' <br />