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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S Roo <br /> OWNER/OPERATOR <br /> AMAk-1 t 1 CHECK If BILLING ADDRESS IAA <br /> FACILITY NAMET>; I�J <br /> SITE ADDRESS F' PESCgt�FRp Ave V/4CV 9530y <br /> 005 Street Number Direction Street Name Cit ZI Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name -- <br /> CITY STATE ZIP <br /> PHONE#1 ExT APN# LAND USE APPLICATION# <br /> (<lls ) SIU -of o I <br /> PHONE2 EaT BOS DISTRICT LOCATION CODE <br /> ( 7-01) 420 - 5221 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> V <br /> BUSINESS NAME PHONE# EXT. <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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: /-/j�L,4A / DATE: Y112 12 2 <br /> PROPERTY/BUSINESS OWNER❑ OPE OR/MANGER ❑ OTHER AUTHORIZED AGENT 13 <br /> If APPL7CANTisnotihe B/LLINGPARTP 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 the or my representative. 13AT <br /> TYPE OF SERVICE REQUESTED: ALLAJ Ot,l N—Av C-m <br /> COMMENTS: APR Z <br /> 12022 <br /> aANJOAQuIN cou <br /> H k% EPS Ty <br /> ACCEPTED BY: ra /, -a 16 EMPLOYEE#: DATE: <br /> ASSIGNED TO: LwA -132 EMPLOYEE#; DATE: <br /> Date Service Completed (if already completed): SERVICE D PIE: <br /> Fee Amount: Amount Pai 5'/ obPayment Date u4� <br /> Payment Type I Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />