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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 5e? <br /> OWNER/OPERATOR \� 1 \ I <br /> CHECK If BILLING ADORES <br /> FACILRV NAME <br /> 1`� G <br /> SITE ADDRESS r'� C ,� �0 a 5330 <br /> �S�efKu ber Direction J b mersst Name CI ZID Code <br /> NOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITUL 0.-A�r Q $T TE(24111 1z5 3 t� <br /> PHONE#1 Esse APN# LAND USE APPLICATION# <br /> PHONE#2 Em BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR - <br /> REQUESTOR <br /> CHECK if BILLING AD0RES5O <br /> BUSINESS NAME PHONE#• Ezr' <br /> HOME Or MAILING ADDRES FAX# <br /> � � 0 53 <br /> CITY E� rp STATE ZIP q 53 <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 flus pplication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standardsl TE and FEDERAL laws.Q I <br /> APPLICANT'S SIGNATURE: DATE: b I� 12O�LZ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHOmZED AGENT 13If APPLICANT is not the BILLING PART) proo 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 pr' �.Ule time it is <br /> provided to me or my representative. - �� <br /> TYPE OF SERVICE REQUESTED: D <br /> COMMENTS: J <br /> FN�gQU/N CO <br /> NSC) 0 PMETA<� <br /> ' 1` �V H <br /> W I -7 ART,yt fNT <br /> ACCEPTED BY: EMPLOYEE#: �)� DATE: <br /> ASSIGNED TO: VI EMPLOYEE#: S✓g DATE: .L yy <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: '�:L? <br /> Fee Amount: -/L <br /> , , Amount Paid - / — Payment Date :7� Z/ ZZ <br /> Payment Type `Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> I , P —lei9� <br />