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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST PA- 0163 /5D <br /> Type of Business or Property FACILITY ID# SERVICE REQU'ESTT# <br /> �Il.v <br /> OWI/�E�R/ PERA OR / <br /> (/L/ �� ZZHECK If BILLING ADDRESS <br /> FACILITY NAME . <br /> C1 0 <br /> SITE ADDRESS <br /> 'Y�_ S K r 5tre¢,Number Direction Street Name Cit jT1 rJ Y Zip Code <br /> HOME or MAILING ADDRESS (If ifferent from Site Address) S'!I_ C <br /> y 5 L 'Gr-lCa,' Or ll Number Street Name <br /> CITY STATE ZIP <br /> (HONE#I) ExT APN# LAND USE APPLICATION# <br /> PHON #Z �� _ /J/'I/J / ExT. BOS DISTRICT LOCATION CODE <br /> ( � ) Cy/too' r <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Ju!'�fAI'7 'I(7( e� ECK If BILLING ADDRESS <br /> BUSINESS NAME ExT. <br /> HOME or MAILING DRESS (/ u/(rL /-1 FAX# <br /> CITY L STATE 5� ZIP 7/ <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 applicati -e that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar s, S and FEC L laws. <br /> APPLICANT'S SIGNATURE.-2 DATE: d <br /> PROPERTY/BUSINESS OWNER❑ OP /MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT 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 atetime it is <br /> �PaSay7Z <br /> provided to me or my representative. E <br /> TYPE OF SERVICE REQUESTED: I I S I V t / mej) <br /> COMMENTS: <br /> 3 O <br /> 102 <br /> SANJOA UIN�TpECT7 <br /> YNLART <br /> ACCEPTED BY: EMPLOYEE#: DATE: Z' <br /> ASSIGNED TO: EMPLOYEE#: U v DATE: � �I <br /> Date Service Completed (if already completed): SERVICE CODE: OLP PIE: J O� <br /> Fee Amount: a Amount Paid �'a Payment Date b I <br /> Payment Type •J:lInvoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />