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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> $ SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ao1Zo&9 o+� Yic-;' U <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> l 17-amoo <br /> FACILITY NAME <br /> SITE ADDRESS K v L Sk ocki-o n L►S Z0 3 <br /> r/lonc� O 1 L.blo t <br /> 1 0 SVeet Number olraction Slreel Name LI Zip DOEa <br /> HOME Or MAILING ADDRESS (if Different from Site Address) 10 ?-9 \ i"t„a9t, (--ire-e rN Or-.3 A c ` —Lc,. c,(\ SVaet Number V $Vast Name <br /> STATf <br /> clT��v��}ori C.H • 95- 21 O <br /> PHONE#1 Em APN# LAND USE APPLICATION# <br /> (209 ) 639 - 7339 <br /> PHONE#2 Ear. BOS DISTRICT LOCATION CODE <br /> P ) 932- 11 1l <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Ed / 1 6fmG n CHELK If BILLING ADDRESS <br /> ej BUSINESS NAME C PHONE# ' <br /> ro Z Z ( ZQJ) q37 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY `' TE ZIP (7-1 <br /> BILLING ACKNOWLEDGEIIIENT: 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 /> COLRVTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: tD / h <br /> PROPERTY/BUSINESS OWNER RATOAI MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLLVG PARTY proofajautherization 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 and at the sa ne it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ��� Q <br /> COMMENTS: �.,, ,L, <br /> (� �j N <br /> NF,gtrHODONMFca�7? <br /> ^w p PpgR MFNT <br /> ACCEPTED BY: EMPLOYEE#: Gr X/�t DATE: 0 /3 <br /> EMPLOYEE#: ^ UUU V DATE:/n �3 Set <br /> Date Service Completed (if already completed): SERVICE/CODE: o PIE: <br /> Fee Amount: - Amount Paid _{, �_ �, `I_, Payment Date <br /> - <br /> Payment Type ` Invoice# Check# 1�Sb 7 — Received By: <br /> J,:— <br /> c-�n <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />