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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />SR© n(o& <br />OWNER I OPERATOR=E 1 ✓n e 114 A Ih� <br />C.� <br />Aft)v,n V1,0 CHECK If BILLING ADORE <br />FACILITY NAME Cot � `i ;"OLI <br />SITE ADDRESS-(; <br />12-S i U Street Number <br />Diremlon <br />oSQ� (J. 1 <br />'—`A Street Name c—C <br />,S c k-6 ✓� <br />city <br />y,5z 1S <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE#t En. <br />(510 23 [q <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 Exr. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # En. <br />I ) <br />HOME or MAILING ADDRESS <br />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 FED RAL laws. <br />APPLICANT'S SIGNATUIkV, DATE: <br />PROPERTY/ BUSINESS OWNERII ff OPERATOR /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT 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 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. pay,,__ <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />Nov 1 2U� <br />SAIV JOAQUIN DEPOUNTY <br />S L <br />ACCEPTED BY: V EMPLOYEE #: DATE: <br />ASSIGNED TO: I V EMPLOYEE #: a DATE: <br />Date Service Completed (if already completed): SERVICE CODE: T1.Z-3 PIE: t 6 I <br />Fee Amount: <br />Payment Type C <br />EHD 48-02-025 <br />REVISED 11117/2003 <br />Amount Paid ,CYRL({,Q I Payment Date <br />IIII'::I22 <br />/{I Invoice# I CCFr�c--* Mil ��''iJ�2��c-�G/t� I Received By:WJ-4d <br />kt� OA��`f �� il-�-� ` FORM (Golden Rod) <br />. a. rot -�&' <br />