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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 /> M(GN&ZCC- ,DOM /N G a CHECK If BILLING ADDRESS <br /> FACILITY NAMEQeti-ew CR-4v1,-t CTS A3 M1C HELI. <br /> SITE ADDRESS SU C - IC ry -C/ ✓� �S o���- <br /> Straet Number Direction Street Nam. r " I{jI 3 I l-Cit ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> rj Street Number Street Nama <br /> CITY dry, _/ , /, STATED ZIP A�+ <br /> PHONE#1 7llJ"( ir APN# LAND USE APPLICATION# ( 1 <br /> Lf ;9' <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR t <br /> S'^y^ CHECK if BILLING ADDRESS <br /> SAY7, PN S Ez . <br /> BUSINESS NAME •y <br /> HOME Or MAILING ADDRESS F/x# <br /> mss sT ( ) <br /> CITY S'-1-b�(G?D�v STATE C�4 ZIP <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 /> 1 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 aan�d,FEDERAL laws. <br /> APPLICANT'S SIGNATURE: / AL <br /> 7 "' `" " / DATE: <br /> PROPERTY/BUSINESS OWNERS O RATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Titre <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: P <br /> COMMENTS: <br /> ECFj; ,� <br /> ' <br /> SM <br /> IN COU <br /> HEAL ONME , <br /> ACCEPTED BY: ��I EMPLOYEE#: r DATE: I 3 TJA- <br /> ASSIGNED TO: ✓Y I/ IO EMPLOYEE#: In DATE: II I 'Ly <br /> rFee <br /> te Service Completed (if already completed):completed): SERVICE COD✓✓E: PIE: I(pO')- <br /> Amount: Amount Paid 15� Payment Date /31 t22 <br /> ymentTypeInvoice#- <br /> 03# 4.q Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />