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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 00D39072:�, SS OOS�o'201 <br /> OWNER/OPERATOR <br /> /;v E,(- <br /> C� `� c`C r�ly,�� I,mc- CHECK if BILLING ADDRESS <br /> FACILITY NAME Lot-k" CC C�c/5 j-\ l <br /> SITE ADDRESS (00 I J <br /> (- •�nke �e`'Vlt ri �{� LoiStreet NumbDirection Street Name City Zip Code <br /> HOME or AMAILING ADDRESS (if Different from Site Address) <br /> 7(0`"1�� C-vo� q-3 Street Number Street Name t�1 <br /> CITYa 'Pu-CA) �a k�� STATE `� ZIP <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# `[ <br /> [PHONE#T EXT BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR \ <br /> CHECK If BILLING ADDRESSP - <br /> BUSINESS NAME �_Oar (' lc- ` PHONE# EX' <br /> v ( ) <br /> HOME or MAILING ADDRESS FAX# <br /> ClD'c��` <br /> CITY { QO(Gt�0 C���\ STATE CyU— 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 an ajahe wo•s�te-� ed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STAT�ff F aws. <br /> l <br /> .APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ �OPERAT9 ANAGER ❑ OTHEK ALITHORILED 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 the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or enviroPYA /site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availableg[1Q a lsawime it is <br /> provided to me or my representative. .� ;�^ EC� <br /> TYPE OF SERVICE REQUESTED: }�a�� V v" v <br /> COMMENTS: (► 0ww^rti v� SA N IRONMENTgL ry <br /> k HEALT}(f) ENZ L <br /> ACCEPTED BY: EMPLOYEE#: DATE: Z 22 <br /> ASSIGNED TO: D�vA� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: (9V I P 1 E: I Lp <br /> Fee Amount: (��i) Amount Paid f S� Q Payment Datej zZ <br /> Payment Type Invoice# Check# rjb3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> S <br />