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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SRmm8c� 3a <br /> OWNER/OPERAT <br /> o I na ic V-V-\ CHECK If BIL4NG AODRES <br /> FACILITY NAM V-nazln -� C <br /> „ <br /> SITE ADDRESS �Xl S] <br /> 2l1 Street Number I Dlreotlon J" Street Name CI Zip Code <br /> HOME or AD (If <br /> MA:I N( DRESS Differes <br /> n from Sit'eAnddresf/,d <br /> lX �+� "' Street Number Street Name <br /> CITY ^ 1_ 1^ M ZIPi-.,�� r <br /> PHONE#1 Y EK. APN# LAND USE APPLICATION# <br /> S I <br /> PHONE## Em BOB DISTRICT LOCATION CODE <br /> { ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> t�/t C iy\ CHECK If/BILLING ADDRESS <br /> BUSINESS NAME "( r, _. . C.n 1' ` J P Ury# Ez , <br /> HOME or MAILING ADDRESS Its ( \ FAR#✓� <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,S and FEDERAL laws. t I <br /> APPLICANT'S SIGNATURE: p ' (sj / lr DATE: I /� lZ3 <br /> PROPERTY/BUSINESS OWNER❑ OPE OR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization t0 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 environmentaUsite 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: <br /> COMMENTS: <br /> ACCEPTED BY: t EMPLOYEE#: -/�=�f DATE: <br /> ASSIGNED TO: c Gw�� <br /> EMPLOYEE wUUU� DATE; <br /> Date Service Completed (if already completed). SERVICE CODE:'l I6! IE; <br /> Fee Amount: Amount Pai Payment Date 31 <br /> Payment Type Invoice# Check# S�`f- I Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> S <br />