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SAN JOAQUIN COUNTY ENvTRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> CON\J� NrENCF 970 R- ° <br /> OWNER/OPERATOR <br /> -Am R3 ) N L I CHECK If BILLING ADDRESS <br /> FACILITY NAME T Q V i (-A S H Q P ,A �] q <br /> SITE ADDRESS tib Q S'- Ce-,14rA ct � v e L 0J) � % v d yo <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1 017 :� N M A&N 0 bill AV fr <br /> /' ( I Street Number lr t Street Name <br /> CITY / I V I IV GJON STATE �^`19 ZIP <br /> L 9 5 33 <br /> PHONE#t Ex . APN# LAND USE APPLICATION# <br /> (60 ) 5a <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Ag-A S112 CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# <br /> (sior c S OTS W <br /> HOME Or MAILING ADDRESS FAX# <br /> I MA LN e 0 A .: & ( ) <br /> CITY Lf yr I .1 /_sr 7o)v STATE C/q ZIP (1 533 <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. q q c� <br /> APPLICANT'S SIGNATURE: '��v. �A1'2 DATE: 45OC"O3 '—OL®OC3 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHomzED AGENT❑ <br /> ffAPPLICANT 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 <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 JOAQUrN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. P <br /> TYPE OF SERVICE REQUESTED: O \'� REC NT <br /> COMMENTS: 41 <br /> E® <br /> chGe of owerS�� <br /> 5 F8 03 023 <br /> IAQU,lpolt4ftCc UN7�r <br /> NSsm 4L <br /> T'y DEpKiiT ENT <br /> ACCEPTED BY: `/ EMPLOYEE DATE: <br /> ASSIGNED TO: _ S(fl`\/�C �� EMPLOYEE#: DATE:Z <br /> Date Service Completed (if valready completed): SERVICECODE: PIE: <br /> Fee Amount: �5� Amount Paid I Payment Date 3 �20 <br /> Payment Type Invoice# ck 5 5 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />