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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> o&,T ZqC- & �6y <br /> OWNER/OPERATOR I Lk <br /> St / �Iq I <br /> CHECK If BILLING ADDRESS <br /> FACILTY NAME C T/ i 'V6 <br /> SITE ADDRESS 171 UnY < Ka �tV Zip Code Number 0lm ❑3 <br /> Street <br /> HOME or MAILING DDRESS (If D1iff;nt from Si Address) <br /> 13 ry ZG Street Number Street Name <br /> CITY ( l STATE ZIP i+,r <br /> PHONE#1 "M- <br /> 1EM APN# LAND USE APPLICATION# 7�S <br /> a s1 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR �— r� <br /> J • C7 LA, CHECK if BILLING ADDRESS <br /> BUSINESS NAME -/ PHONE# E <br /> wJ ; �EJE Q jr <br /> �f <br /> � 38 .� <br /> HOME Or MAIlNG ADDR S FAx# <br /> o(L rJ Z t - ( ) <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: O Z42-711ZOZ <br /> PROPERTY/BUSINESS OWNED OPERAT / MANAGER ❑ THER AUTHORIZED AGENT❑ <br /> !f APPL/CANT is not Lh¢BILLIN RTY proof of au Hzation 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/sI a assessment <br /> information t0 the SAN JOAQUIN COUNTY ENVIRON ENTAL HEALTH DEPARTMENT as soon as it is available and at the ylle it Is <br /> provided tome or my representative. <br /> TYPE OF SERVICE REQUESTED: U v / • C <br /> COMMENTS: <br /> RQl1/lye oa13 <br /> OpMFNTq(Ml <br /> ��ENT <br /> ACCEPTED BY: CC.✓'✓'-ti S W EMPLOYEE#: DATE: <br /> ASSIGNED TO: ai ,Z..G I/ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I PIE: <br /> Fee Amount: Amount Paid i P. Payment Date c X a <br /> Payment Type Invoice# Check# Received By: <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />