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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SS RVIICI�E UEST� <br /> OWNER/OPERATOR LI(I( <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS -,1 I G t\SSL �. C � " U�te N er Diredlon C-( - Street Naame � City Cede <br /> HOME or MAILING ADDRESS (If Different from Site Address) Sy\I- �2 <br /> 1�1 '� VN�G Street Number U Street Name <br /> CITY STATE zip S�c�k� (.Q r <br /> PHONE#1 E`T• APN# LAND USE APPLICATION# <br /> ( 11 YV 9.`v�at V I O 1 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# En' <br /> T vl R Tq UEr� 0, 2-4}4 <br /> HOME or MAILING ADall�lrD'RESSt �A,, \(3% <br /> CITY <br /> CITY `�11,il. �� STATE CA zip rl \ <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized)a`ge'nt 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,S and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: " - DAIUyr�1 g l Z L3 l Z L <br /> ro <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> If�APPLICANT is not the B7LL7NG PART}'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 environme taVslte assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and e time it is <br /> provided to me or my representative. r t <br /> TYPE OF SERVICE REQUESTED: 'F000 ` I`, I V1S eaUV\_ All^ VED <br /> COMMENTS: 3 022 <br /> �j��QUlI y CDU <br /> N TH EP4 1 y <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: LG_ <br /> Date Service Completed (If already completed): SERVICE CODE: <br /> Fee Amount: Amount Pa �[� Payment Date /3 <br /> Payment Type ` Invoice# Check# Received By: <br /> 1p <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />