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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />67,4 <br /> <br />FACILITY ID # SERVICE REQUEST # <br />OWNER/OPERATOR <br />CHECK if BILLING ADDRESS <br />, _FACILITY NAME bwiriozetciae___ 6 em___ <br />, SITE ADDRESS. 6 gi- wrC NumberDirection 64 r clf r A a r il l'' 01-Crie'. -27f11 <br />City Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Crry STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR p <br />i a-ivit-rv? <br />BUSINESS NAME <br />rA CHECK if BILLING ADDRE <br />TV-0-0----- PHONE # , <br />eb\Ci } <br />EXT. <br />ds 5 il <br />HOME or MAILING ADDRESS 6 6 Ox '7 /a-- <br />PAX # <br />(AT 3'3 )/- 3-7 <br />CrrY <br />1/07er-e9 4'240 STATE c4+, ZIP 76' 0),.../,—) .e <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 /> <br />1. —7 APPLICANT'S SIGNATURE: DATE: / <br />PROPERTY / BUSINESS OWNEfrEr OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <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 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: 2A) <br />COMMENTS: <br /> <br />ACCEPTED BY: ' e A i <br />/ <br />EMPLOYEE #: DATE: / 43 <br />ASSIGNED TO: /1 ' EMPLOYEE #: co 2 /3 DATE: e^ ..?„ 13 <br />Date Service Co pleted (if already completed): SERVICE CODE: P / E: 0 a" <br />Fee Amount: ago. 0--0 Amount Paid 02(.5---n of .0-C2 Payment Date <br />Payment Type Invoice # Check # 7/ I/ .7 <br />n72,491/.., <br />Received y (: AP <br />END 48-02-025 <br />REVISED 11/17/2003 SR FORM (Golden Rod)