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SAN JOAQUL, .OUNTY ENVIRONMENTAL HEALTH, PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID## SERVICE V O REQUEST/## <br /> " �`" <br /> OWNER I OPERATOR <br /> na} r /h j (/\I /J mp CHECK If BILLING ADDRESSE] <br /> FACILITY NAME I 1 e 1 /r Y <br /> n44 (i <br /> SITE ADDRESSel Nf4"A41t ft 7Z1YCo1gtkmber 111 5 n d <br /> a <br /> HOME Or MAILINGADDRESS (If Different from Site Address) /`^ �t�V/, <br /> 5` 1 ArStreet Number ✓ 1o/ Stren <br /> et Name <br /> CITY STATE ZIP <br /> PHONE#tT• APN# LAND USE APPLICATION# <br /> V ) 5-70 - ggkif <br /> PHONE#' 5-7 O ��� EXT BOS DISTRICT LOCATION CODE <br /> 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �D' 1.pv�trI��-{ ah ampt CHECK If BILLING ADDRESS By <br /> BUSINESS NAME i � P 1 //( 'I I PHONE# FXT. <br /> I1 ) <br /> HOME or MAILING ADDRESS I FA%# <br /> ( ( ) <br /> CITY STAT ZIP <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, SsT-AT��E and F DERAL laws.--T- <br /> APPLICANT'S SIGNATURE: 'q' Oil$ �j�—._� CJI DATE: o 7 — I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLrcANTisnotthe BILL/NGPARTY 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 ame time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Y <br /> COMMENTS: <br /> 006"V d CDS s L' l am JU4 Fiv o <br /> 20 <br /> N N FNM& 0ppp0HTy <br /> ACCEPTED BY: t-A IA ( A EMPLOYEE#: 3� DATE: <br /> ASSIGNEDTO: , EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: 3 <br /> Fee Amount: 11;:217-0 Amount PaidI cJ '1 Payment Date ENT <br /> Payment Type Invoice# Check# Recei fC <br /> EHD 48-02-025 SR FORM(hol=od) <br /> REVISED 77/17/2003 �? <br /> SAN JOAQUIN COUNTY J <br /> 5 2".7, ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br />