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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> TA 00DO39q SR 8 8 <br /> .OWNER/OPERATOR i <br /> J \/n r CHECK If BILLING ADDRESS <br /> FACILITY NAME L©S 1 r-; MoS C �+�-r� /� <br /> SITE ADDRESS 2 l� o A `v-PoT ul ) J 1 VCK�n Tr 20 to <br /> Stree[Number Direction Street Name Cit ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2 <br /> Strlt Number " TT r e�SFRAMNeme v <br /> CRY (3 C V I ) STATE C �, ZIP l <br /> PHONE#t Exr. APN# LAND USE APPLICATION# L <br /> (2N 52-- logo <br /> PHONE#Z Ess. BOS DISTRICT LOCATION CODE <br /> ( ) <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 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:'�(�C?&UQ+t&N/ �t�U.C¢ 5 l'RIOeYC, DATE: <br /> PROPERTY/BOSINESS OWNER[3 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLINGPART)' proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator or 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 at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: �Q 4� V/'c O t C CL' IVIS t{G(�g�v , <br /> COMMENTS: CtVa my OP V v V\a OCT/ D <br /> SAN 7 ?022 <br /> Mo,nd�, — 'rridot, <br /> 8 I �O Qt,11/v y��QEPgRNTaTUN <br /> f� 1Y <br /> ACCEPTED BY: a _t t. Z EMPLOYEE M DATE: 'O <br /> ASSIGNED TO: 'T !!A goric^Kii 1rx EMPLOYEE DATE: (O 7' a^la <br /> Date Service Completed (if already completed): SERVICE CODE: oto I P E: 1013 <br /> Fee Amount: �Cj� Amount Pai /S� U Payment Date �9 7 2 2 <br /> Payment Type Invoice# Check# Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />