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SAN JOAQUOOUNTY ENVIRONMENTAL HEALTIOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> =�' G ) 3 C 06 ► i 9 <br /> OWNER/OPERATOR � `I < < <br /> 1 T f� to 11 ��`n`„�t�r' CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME f-rDh 1"' • r�/�ti l�U�- <br /> �/�. n n ,�o ^ <br /> SITE ADDRESS IZ�J2 A�Vr���,� W ou M Y� <br /> . I ` a c� `�5s3� <br /> Street Number Dir tion Street Name L I Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ('Ln ) I a� 5-7 uyC�a 6 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> 17D 11 <br /> C, <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR `► <br /> kV6 n , _ Tevr� CHECK if BILLING ADDRESS❑ <br /> ��""rrr'C„C iiiWWW <br /> BUSINESS NAME E cve-vk C-0a sk ov PHONE EXT. <br /> d9 `"f �'tI�C)L(0 <br /> HOME or MAILING ADDRESS FAX# l <br /> 9D5 ' lovW1.. V-&. (2,1) t) L-- 9 - Ko44 <br /> GCS <br /> CITY E5 STATE CA, ZIP 415-,,-L(5 <br /> �7 1. <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 a d laws. �7 <br /> APPLICANT'S SIGNATURE: DATE: / <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT O NrCskff- 4 RlA-Ir V—�"V' <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Titt e E)pevak1bt�S <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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. ,�•iqY <br /> TYPE OF SERVICE REQUESTED: C j` <br /> COMMENTS: A <br /> O <br /> �0/0' s ?o>> <br /> N� Ty/�FpMFH��H�y <br /> gRTM HT <br /> ACCEPTED BY: � ` EMPLOYEE#: SO— -5 DATE: <br /> ASSIGNED TO: EMPLOYEE#: { / DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: r; <br /> Fee Amount: Amount Paid - � Payment Date S <br /> Payment Type T ,'`,; Invoice# Check# Rec ved By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />