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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> un'f FA�(D 2531 S'(Z <br /> OWNER/OPERATOR b '�OI Ip <br /> HECK If BILLING ADDRESS <br /> FaclurY NAME - <br /> _ r n cia1 <br /> SITE ADDRESS too I-1 <br /> LL�LJ! W I�iVe� MStm-.. <br /> Street Number Direction Street Name I <br /> city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CIN1"� STATE .ZIP <br /> 016S 9.o <br /> PHONE#1 V V E.T- APN# LAND USE APPLICATION# <br /> (ZI>`I ) (p2p-0�Z2 <br /> PHONE#2 Exr. TBOS DISTRICTLOCATION CODE <br /> ( q ) 253- o <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR ( f CHECK if BILLING ADDRESS <br /> BUSINESS NAME? \a� PHONE# Exr• <br /> HOME or MAILING ADDRESS FAX# <br /> CITY YS _ „^ STATE C4� ZIP 0163616 <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: �)' ;2:�� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OP RATOR IVIANAGEIX OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the ILLING PARTY,prop 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 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 /> 1Z - O�t a.e� �t ti r pGLL t•..—a r <br /> r <br /> ACCEPTED BY: ` - �V EMPLOYEE#: - DATE: L G(/ Z3 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/ <br /> Fee Amount: ( 2 Amount Paid i Z Payment Date �® <br /> Payment Type Invoice# Check{/# Received By: <br /> EHD 48-02-025 Cot? ` ' bol ) 3 I 0 SR ORM(Golden Rod) <br /> REVISED 11/17/2003 <br />