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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT�2 0573 906 6 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# PRVICE REQUEST# <br /> (�2Uc�'L1 SS jf <br /> OWNER/OPERATOR ` .� <br /> n t 'Vaq <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME s <br /> SITE ADDRESS 2111 JD J C /j <br /> St``ref(e``tTTNumber Dlrectlon 1 Street Name W t/l J I Codew- <br /> HOME or MAILING DRESS (If Different from SiCCte ddress) <br /> Oe- J Street Number Street Name <br /> CITY Q STATE (�,R ZIP q53 "� <br /> PHONE 91 ExT• APN# LAND USE APPLICATION# -'( J <br /> (&;a) qy5 ( l4 <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> /y r``CCC///^(?-`J <br /> ` CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONEo l l e VP�N�# �� Ezr. <br /> le- <br /> HOME or MAILING ADDRESSO 01 FAX# <br /> S� ( 1 <br /> CITYKa r' ry STATE ZIP Cts <br /> 3 S'--7 <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. p <br /> APPLICANT'S SIGNATURE. DATE: Ds— I l <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is no 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 ssmeentt <br /> information t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and a[Ill <br /> provided to me or my representative. RECEIVE <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> SAN JOAQUIN COU 4TY <br /> ENVIRONMENTA <br /> HEALTH DEPARTM NT <br /> V rt,Qfsh <br /> ACCEPTED BY: LA v <br /> M EMPLOYEE#: v DATE: 1r����/tttrrr 2y <br /> ASSIGNEDTO: h / EMPLOYEE#: V DATE: /Iv/ <br /> Date Service Completed (if already completed): SERVICE CODE: i E: I uEJ 3 <br /> Fee Amount 15RO Amount Paid fk k2— _ Payment Date t,. li <br /> Payment Type Invoice# W6#l 3 72 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> S <br />