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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FA 2 3 OS S` 12` <br /> OWNER/OPERATOR <br /> ^ � CHECK If BILLING ADDRESS <br /> FACILITY NAME K <br /> L)C & �, I__' �'/I � /� <br /> SITE ADDRESS �71,Q I O FA G t�l(,' � �� ��L �SZtde <br /> Slreat Number Dlredlon Street Nama � Cit ZipCode <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> t)-2 C Street Number Street Name <br /> CITY V,t n �,��� STATE ZIP <br /> PHONE#1 l� Ear. APN# LAND USE APPLICATION# <br /> (209) G <br /> PHONE#2 Ezr, <br /> BOS DISTRICT LOCATION CODE <br /> (Zo ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CiYY1Y OW 0 Ch 610 <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ear. <br /> Q z0C <br /> HOME or MAILING ADDR SS FAx# <br /> - I 1 ) <br /> CITY n10`ki V, -�-N STATE cc,, ZIP h 50 <br /> `` <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: � _ t J DATE: lA /r ! ! g � <br /> PROPERTY/BUSINESS OWNER OPERATORTOR MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> IfAPPL/CANT is not the BILLING PARTY proof ofauthorization 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 arPAYMMIne it Is <br /> provided to me or my representative. RECEIVED <br /> TYPE OF SERVICE REQUESTED: �Fdo <br /> COMMENTS: <br /> CIVAVkC�C 6C C)wvLC�V�v"'1� SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: LC EMPLOYEE#: DATE: I <br /> Date Service Completed (if already Completed): SERVICE CODE: Cl .0 PIE: <br /> Fee Amount: I 2�n Amount Paid S a _ Payment Date !� Z <br /> Payment Type v`5 /T Invoice# ck# YS�3 U-6 Ll Received By: <br /> EHD 4&02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />