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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �rvf qs Secs ACOP5391 SQoDS(o35 <br /> OWNER/OPERATOR \'� _ r <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME U (� r 1� n (_ ,yI �aq+T <br /> SITE ADDRESS X1311 NI , (�/ ' t/�0I�-r V0 57' L ro� C4 h. mom <br /> Stme Number Dlrectlon Street Name Cil Zi Cotle <br /> HOME or MAILING ADPRESS (ifDifferentfrom Site Address) <br /> (71 1 Street Number C,4— Street Name <br /> CITY STATEIP <br /> a� c+0N y(Sf <br /> PHONE#1 EST APN# LAND USE APPLICATION# <br /> (tom ) 7 04 (336)-- <br /> PHONE#2 Ev* BOS DISTRICT LOCATION CODE <br /> (961 ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME ' 1n / ' PHONE# EM. <br /> �i 0 L <br /> HOME or MAILING ADDRESS L, p ^J�r -� (A%# ) <br /> CITY �`I _Ll�t �, „r i (� \> 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 /> TURF (f'lt'lai l � <br /> APPLICANT'S SIGNA � DATE: OZ,2 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/4ANAGER ❑ OTHER AUTHORIZED AGENT[3 <br /> IfAPPLtCANT is not the BILLING PART K 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. <br /> TYPE OF SERVICE REQUESTED: (� {—� R AA <br /> COMMENTS: � p I Q ytt�sl„r� rR� O ,•O'_ <br /> y�C��°N,yFNOU <br /> Fagg '9C <br /> ACCEPTED BY: EMPLOYEE M Zl 3 DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Comple d (if already completed): SERVICE CODE: PI E: I 1 <br /> Fee Amount: ,Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By:1�-C/ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />