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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S000 3S5y <br /> OWNERJ OPERATOR <br /> O-SE <br /> ,pi 1. ���SI��C �Nn ^ , ^A GZ CHECK if BILLING ADDRE55� <br /> FACILITY NAME t 1T 'L N�1 r1,vV <br /> S �u> Dt (ALf Do S <br /> SITE ADDRESS <br /> S 1�uf`IC AC t r 1GumName <br /> - o <br /> Street Nber Direction StrV N <br /> eet Name Clt ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) / Os— S GtVC�I A 6+ <br /> Street Number J Street Name <br /> CITY S;��K„�� STATE G. /t ZIP 9 SZUS <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# I <br /> (709 ) (,yD - 615-17 <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> (ur, ) L4 S l - X33(p <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �jIr 1 191 <br /> Qs(S194 &-4C y-SI CHECK If BILLING AOORESS <br /> BUSINESS NAME J tS ! .+ P ONE# EXT. <br /> HOME or MAILING ADDRESSFAz# <br /> S <br /> JOS 6 L)IJO I A L+ I ) <br /> CITY S•-t-o LK-t-o tJ STATE C /t ZIP A S-Zo 5- <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: v ! DATE: `I 115-- l-2 ( <br /> ERTY/BUSINESS OWNER El OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> If APPLICANT isnot LBILLING 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 environ men�q��II ee assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and l]Z-eSflj� yjer it is <br /> provided to me or my representative. /fir ft?* <br /> TYPE OF SERVICE REQUESTED: AP <br /> COMMENTS: 20 <br /> e yEgl N0 21 <br /> ACCEPTED <br /> /t MFNT <br /> ACCEPTED BY: Rua 9 EMPLOYEE M ry/) DATE: <br /> ASSIGNED TO: EMPLOYEE#: ✓V DATE: �1 <br /> Date Service Completed (if already completed): SERVICE CODE: QI �f P/'E:' <br /> /)f^ <br /> Fee Amount: Amount Pal L S�r T Payment Date S v <br /> Payment Type I Invoice# Check# 23 <br /> Receiv <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />