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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> g <br /> OWNER I OPERATOR CHECK If BILLING ADDRESS❑ <br /> �A-�A1J S t t� H N�V Q�� VA-V 2 . <br /> FACILITY NAME <br /> - t t_t_ S-T-ON 9- tea: Cz LJS -170(\J le- <br /> SITE ADDRESS. 1 O S•q t I 11t,L� '�k,t,t,,l,( L �f' �L+_� 0�s3"'� � <br /> Streel Number Dlrectlon Street Name \ Cit ZIp Code <br /> HOME{or MAILING ADDRESS'(if <br /> ID'iff,e�r{¢¢ntt�fr�oin S�i�t§(Address) <br /> 1 t7 2 �' r✓�^'"�"'" — Street Number Street Name <br /> .CITY , II 'n STATE zip <br /> PHONE#1 Exr• - APN# LAND USE APPLICATION# <br /> ( 510) <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME. r v /\`j DS O11NIV <PN�1NE# Ex'• <br /> 1,0 34b- 6r 6 <br /> HOME Or MAILING ADDRESS ,O Zc V R'r, PAX# ) .. <br /> CITY 1.A&k',J �ace(.t�i2 cul STATEn A ZIP S�q �• <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(rd <br /> application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stand ,STATE and FEDE L laws. <br /> APPLICANT'S SIGNATURE: ,.D;T ;, �� <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> IJAPPLICANT 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 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. 1% <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: ,app 21 <br /> SANJOA <br /> R ROHM@ COUN <br /> e' �ITiIDFPARQ Nr <br /> ACCEPTED BY: �. EMPLOYEE#: 7 ? D DATE: <br /> ASSIGNED TO: t EMPLOYEE M 11 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: W IIE: V2, - <br /> Fee Amount: Amount Paid l / Payment Date 22 <br /> Payment Type Invoice# Check l C) S`e Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 wl, (LX1�, <br />