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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Sr4, S2( <br /> OWNER/OPERATOR r I, <br /> eIM &L CHECK If BILLINGADDRE <br /> FACILITY NAME <br /> h0G �; � c� 5 <br /> SITE ADDRESS zWE) T ' 1-S reef Name mr 1Iyll wa✓ �G H q�20 <br /> Street Number Direction d i city Zip Cade <br /> HOME or MAILING ADDRESS (If Different from Site Address) �/ /4 _� � L n 5�e /G Z <br /> Street Number f-+� Streat Nama <br /> CITY "IUL� ( STATE ZIP 9 <br /> PHONE#1 �•(/ Er. APN# LAND USE APPLICATION# <br /> r (/q ) yV— @OCP ( <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDG NT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be ' d 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: DATE: nSy2 <br /> PROPERTY/BUSINESS OWNEILO OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> IfAPPLICdMCis 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available ai jhe same time it is <br /> provided to me or my representative.^^ — <br /> T vv rM <br /> TYPE OF SERVICE REQUESTED: 4 <br /> COMMENTS: <br /> 1 ?022 <br /> '�1C;0R1)NME/vDGNTy <br /> �Q T ApT <br /> ACCEPTED BY: lvv— EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: I v <br /> Date Service Completed (if already completed): SERVICE CODE: D PIE: <br /> Fee Amount: '�Z Amount Paid15a_ Payment Date <br /> Payment Type Invoice# C 5[.� �i Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />