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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �I"tom Sg a) 2-- <br /> OWNER/OPERATOR �d N � S <br /> CHECK if BILLING ADDRESS E] <br /> FACILITY NAME <br /> SITE ADDRESS 06 0( ���� d LlV-atA,'-- 9s�3C� <br /> Street Number Direction Street Name City 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 /> ((101 ) 3&I - L D 3 3 D4q/__ J �/,/ <br /> PHONE#2 EXT. BOS DISTRICT11 OCATION CODE <br /> IF�t <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Wr <br /> A <br /> HOME Or MAILING ADDRESS Fax# I� <br /> ( ) JAN <br /> CITY STATE ZIP SANIoA 20 <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or aut �i'14 R ; I , <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated W41 o_ject <br /> or activity will be billed to me or my business as identified on this form. TT <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,Standar s,ST E an FEDERAL laws. <br /> APPLICANT'S SIGNATURE: J DATE: 1114-1w <br /> PROPERTY/BUSINESS OWNER;i� OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <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. / <br /> TYPE OF SERVICE REQUESTED: Co rt� <br /> ' -1 v., A 6!0(' mo j fell* i I�17lwxf2�2 c <br /> COMMENTS: —rc) /r_`01/ K VIC— 7� Af <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE' <br /> Date Service Completed (if already completed): SERVICE CODE: i'1 P,E: <br /> Fee Amount: S Z Amount Paid �S�r�r� Payment Date <br /> kM <br /> Payment Type I Invoice# Check# /63 Re eived By: <br /> EHD 48-02-025SR FORM(Golden Rod) <br /> REVISED 11/17/2003 ` C !�1/ 9��� 7i 6 L � -ro � /���1 <br />