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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> VA r - r SRoo 2(017a <br /> OWNER I OPERATO CHECK If BILLING ADDRESS❑ <br /> FACILITY NA �p< /7�j ry �! <br /> SITE ADDRESS -7x <br /> C'r].LJ J Ljj��/al-'// -6/1✓/ ���� <br /> Sheet Number Direction IKStmet Name at r L 21 Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) � <br /> / Stree, umber Stre,V/7 <br /> CITY �/1 S If 21P7 n� <br /> C <br /> PHONE#t Exr. APN# LAND USE APPLICATION# p�(J <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> i -J <br /> CONTRACTOR/ SERVICE RE UESTOR <br /> REQUESTOR ,, ./, �Z CHECK If BILLING ADDRESS <br /> BUSINESS Nn - / A -C' Ute' P - �-r/ E <br /> AM <br /> HOME Or MAILING t5- / 4n '190 a% FAX# a(�J r _Jf(J <br /> CITY a STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent ofsame <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,Standar , ATE and FED laws. ` /J <br /> APPLICANT'S SIGNATURE: JJJ/ ryT�, ��� 7� DATE: <br /> PROPERTY/BUSINESS OWNERL OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPptIcANT is not the BILLMG PARTY 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 envirouiNnntal/site assessment <br /> Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available A A!f�,�D�time it is <br /> provided to me or my representative. R ••I T <br /> VIE <br /> TYPE OF SERVICE REQUESTED: D <br /> COMMENTS: 2QJ2,yA dO <br /> Hp'ZAQU <br /> �RONMf OU,y7Y <br /> HOE.ARTM NT <br /> ACCEPTED BY: _ EMPLOYEE#: L13 DATE: ' Z L/ L Z— <br /> ASSIGNEDTO: Al K& f EMPLOYEEM L I DATE: 1•�61 11 2-2- <br /> Date <br /> ZDate Service Completed (if already completed): SERVICE CODE: P I E: 3 <br /> Fee Amount: Amount PalIS(OQ Payment Date <br /> Payment Type Invoice# Check# Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />