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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property Jj 6P FACILITY ID# SERVICE REQUEST# <br /> > a LA tvLOO$ 5'9b <br /> �WNER/OPERATOR <br /> i � A CHECK if BILLING ADDRESS <br /> FACILITY NAME r V0//03 Q rzoil el C <br /> ySITE ADDRESS SI/d efl /` # I� 0"• /M 5/(/C 1�„ X15 Z06 <br /> �l <br /> StreetNumber Direction —CA' S teat Nama CI 21 Code <br /> }H.OME or <br /> rrJMAILING ADD.Rn (If Diff ent from Site Address) 1 1 19 ���O f•l w,q� <br /> D , e- WQ SttreetNu(mbar (5/treetNameV[ - <br /> �Cm' STATE ZIP <br /> PHONE#1 Ex*• APN# 1Y7_ 17w-I� LAND USE APPLICATION# <br /> (92'5 ) 5'VVO/Z <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> (9zs, 03 -1f15 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESSEJ <br /> BUSINESS NAME PHONE# Ear• <br /> HOME Or MAILING ADDRESS FAX# _ <br /> CITY STATE 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 /> 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,ST � ED 3w7�01'r� <br /> APPLICANT'S SIGNATURE: 7 DATE: 3 Z S/Z/ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT 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 die <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Aame time it is <br /> provided to me or my representative. iQY <br /> TYPE OF SERVICE REQUESTED: C <br /> COMMENTS: �q B <br /> ?S ?0 <br /> h%Z <br /> 7ipfP,eCOUN NTY <br /> BArp <br /> ACCEPTED BY: EMPLOYEE#: �/? DATE: <br /> ASSIGNED TO: A-� 114, _ T EMPLOYEE#: i J DATE: <br /> Date Service Completed (if already completed): W SERVICE CODE: ro 6 1 E: <br /> Fee Amount: Amount Pa i D Payment Date Z� <br /> Payment Type Invoice# Check# ! ` Dso- Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br /> Q 1�0 5tii�15� " <br />