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SAN JOAQUWOUNTY ENVIRONMENTAL HEALTHOPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#FA <br /> a a/ <br /> OWNER/OPERATOR v-I /q <br /> 41 E 7J CHECK If BILLING ADDRESS <br /> FACILITY NAME \M-en <br /> SITE ADDRESS \M <br /> 'f• r�C' I `-Yyt S � aS3�6 <br /> Street Number Direction Street Name `Cit Zi Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Addres <br /> ;2-5407 <br /> Street Number Street Name <br /> CITY�� OJM 1'1 STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME `T�i Vh /�_ hs}ru p Pj# �14S bi Exr. <br /> HOME Or MAILING ADDRESS �p FAX III 7 U <br /> 2 vtv�utt� 262 (8311 ) LITT• Wil <br /> CITY STATE ZIP �Qninh� tnA� A ? <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 thLe <br /> work t be performed will be done in accordance withal] SAN 70AQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and aws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> 1,fAPPL/CANT is no!the B/LL/NG 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 70AQUIN 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: LJ pp,YM <br /> COMMENTS: <br /> JON - 1 2012 <br /> JOAQUIN COUNTY <br /> SENVIRONME,NTA'-N <br /> HPAL-TM DEPAFl <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: f P I E72 <br /> Fee Amount: Amount Paid ffi 3 Payment Date 6 /1111 Z <br /> Payment Type Invoice# Check# Z 3�' 2Received By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />