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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or PropertybFAC <br />JITY�D #�� <br />M <br />SERVICE REQUEST # <br />HOME or MAILING ADDRESS <br />r'A- (� <br />11 <br />5rzoC)8lo2(2 <br />OWNER I OPERATOR <br />/} y //aJc) C /e <br />( C` z <br />�� na F4 C i`'/ t CHECK If BILLING AODRE <br />FACILITY NAME �I , <br />er y <br />Lf G ( 01�01-71� SV Z <br />SITE ADDRESS /J ZVViL_C <br />` o II„« Q,I �`�, Lne � <br />/f"� <br />1•I�P/y(/ T `^Strete't <br />S��C Ov+ <br />street number <br />Direction <br />Nama <br />CI <br />de <br />Zip Code <br />HOME or MAILING A/D-DRESS (If Differentfrom Site Address) <br />ACCEPTED BY: <br />3 G Ct el - o L 9 <br />Street Number <br />Street Name <br />CITY -51 v C t-1STATE <br />ZIP L7,5 -G <br />PHONE #1 Enr. <br />G <br />APN # <br />Date Service Completed completed): <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 # EXT. <br />HOME or MAILING ADDRESS <br />FAx # <br />CITY STATE ZIP <br />BILLING ACKNOWLEDGEMEI>1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or roject 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 RAL laws. 6 <br />APPLICANT'S SIGNATURE DATE: 6 I— 03 <br />^Z 2 <br />PROPERTY / BUSINESS OWNER❑ 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, 1, 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. <br />P <br />TYPE OF SERVICE REQUESTED: V <br />y "�4'� <br />N <br />COMMENTS: <br />D <br />✓AN 03 <br />SA <br />JOA <br />Heq�TNa� IN <br />IEC7-4L <br />ACCEPTED BY: <br />EMPLOYEE#: <br />DATE: <br />ASSIGNEDTO: <br />-(if -already <br />EMPLOYEE#: <br />DATE: <br />Date Service Completed completed): <br />SERVICE CODE: (AD <br />PIE: 3 <br />Fee Amount: I ' <br />Amount Pai <br />/S& DO 1 <br />Payment Date <br />z <br />Payment Type <br />Invoice # <br />Check # %5 L81 (D /S <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />