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i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE REQUEST # <br /> OWNER / OPERATOR 1 , ,�{ n <br /> f2joLll� ` y � �j e / J �/ ECKIfBILLINGADDRES <br /> FACILITY NAME Zfl O L✓� v1 Lwwr �\ 9 rt, <br /> SITE ADDRESS �tJ � 2 3 �� <br /> Street Number DI a tlo 5 eet a e cit ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) �— <br /> � � ~� Street Number Street Name <br /> CITY STATE zip <br /> PHONE #1 <br /> C/s71 / � /t k/ 6q4 <br /> / Exr. APN # LANE) USE APPLICATION # <br /> 0 l/�/" Y <br /> PHONE #2 EXT. BOS DISTRICT LOCATION CODE <br /> t <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR t2 r � • 'yA UA �Q� <br /> rC .W CHECK if BILLING ADD ESS <br /> BUSINESS NAME 1 PHONE # EXT• <br /> HOME Or MAILING ADDRESS �- I I FAX # <br /> t W t ) <br /> CITY �� / STATE ZIP <br /> BILLING ACKNOWL DGEMENT: 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 or <br /> activity will be billed to me or my business as identified on this form. <br /> 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: DATE : 2 1L2P2 <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, I , the owner or operator of the property located . at the above <br /> site address , hereby authorize the release of any and all results , geotechnical data and/or environmental /site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEAARTME T s soon as it is available and at the same time it is provided to me or <br /> my representative. "r1<0 <br /> TYPE OF SERVICE REQUESTED : g ,�nS CG'{"I d /�-1 '{' �� . P� • , T <br /> COkIMENTS : <br /> FEB o <br /> sq 7 <br /> A �OAQM <br /> 20 3 <br /> N UI <br /> N� <br /> LTH pE Ecot <br /> NTy <br /> ACCEPTED BY : �\ / it �� EMPLOYEE # : DATE: NT <br /> ASSIGNED TO: /r A ���VX/r C L� EMPLOYEE #: DATE: <br /> Date Service Completed ( if already completed) : Z Z I SERVICE CODE : �2( P / E:& <br /> Fee Amount: ); l • f c l� Amount Paid � / �b Payment Date 2 <br /> Payment Type a Al+ Invoice # Check # IES SS3 7 7 Received By : <br /> e f�v DWaM A P�� -finet <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> 07/ 17108 <br />