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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (.e �a �p �/363 �o <br /> OWNER I PERATOR _ <br /> CHECK If BILLING ADDRESS <br /> FACILITY ia Cos <br /> I vl l d <br /> SITE ADDRESSMo <br /> .�.� $� 1 /_ dew 4 _, Tn 57 <br /> { I! S ?Street Number Direction Street Name /"LO Cll rte/ s'2`i'`6'ode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> („(_o 14 <br /> I✓Q Street Number Street Name <br /> CITY STATE zip <br /> TSA s32t <br /> PHONE#1 Ew. APN# LAND USE APPLICATION# <br /> (510 ) Llql 412-5 <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME -I n PHONE# E., <br /> �- S1ti/T 2 elk / <br /> HOME or MAILING ADDRESS v r7 FA%# <br /> L �/Jl 1 ) (7,532 <br /> � <br /> CITY 12r-A STATE Cc, zip 7 ,[+3 2 1 <br /> BILLING AC OWLEDGEMENT: 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,,TSTATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: [tivYc d/ /�jl f C� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANA R ❑ 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 die proper"WAAN. <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/ it��'�/d��s����� t <br /> Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at thRErxRaltM <br /> provided to me or my representative. nn p <br /> FEB <br /> TYPE OF SERVICE REQUESTED: C a 3 <br /> COMMENTS: /' i SAN JOAQUIN CO NTY <br /> 1,( O GCJ�iLCyS /� ENVIRONMENT <br /> (, V HEALTH DEPARTMENT <br /> ACCEPTED BY: ![-(r _ L EMPLOYEE#: $ DATE: 2J l d Z <br /> ASSIGNED TO: CY-Z( EMPLOYEE M DATE: 2 /C)12 <br /> Date Service Completed (if already completed): SERVICE CODE: �/� / P/E: /O_O <br /> Fee Amount: l s Amount Paid s _ PaymentDatep ( ! 1 <br /> Payment Type S Invoice# Ch€Ck# !5-?t) 2,v Received By: ALZ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />