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r <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> F Q0o-gs05t-4 <br /> OWNER/OPERATOR p/qJ <br /> ✓� �� 1 '� CHECK If BILLING ADDRESS� <br /> FACILITY NAME <br /> .nom <br /> SITE ADDRESS /0 <br /> Street Number Direction rUD, Street Name 7J�CPI•1 V'/1 _L/ Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) r'NL,� <br /> StreePNum�er rl nl Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EST• APN# LAND USE APPLICATION# , <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> •` Vt �t� CHECK If BILLING A00RE55O <br /> BUSINESS NAME . 'I� rK� , L PHONE#, � r EU. <br /> HOME or MAILING ADDRESS �I FAX# <br /> I .. <br /> I rlc�R1n T ( ( ) <br /> CITY _ lace STATE 04 ZIP CAf 'it <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. �l <br /> APPLICANT'S SIGNATURE: ` DATE:2,I 3/?, t/ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPUCANT is 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 located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or env ment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available i e it is <br /> provided to me or my representative, q D <br /> TYPE OF SERVICE REQUESTED: '� P lCti� CL c,. ' 3 202 <br /> COMMENTS: j D NM NT,U( ry <br /> ePAR7-teN7. <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: ( EMPLOYEE#: DATE: 1/ <br /> Date Service Completed (ifaireadycompleted): SERVICE CODE: C/h PIE: <br /> Fee Amount: J _ Amount Paid Payment Date a 312 2 <br /> Payment Type Invoice# Check# Received By: VW. <br /> EHD 45-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />