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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Properly FACILITY ID # SERVICE REQUEST # <br /> Amo �_ �� Od�-$(a52 <br /> OWNER I OPERATORT CHECK if BILLING ADDRESS❑ <br /> 1 <br /> FACILITY NAME r , e cp <br /> V Y Ci L � N � <br /> SITE ADDRESS 1', � 'l W C.harw W <br /> Street Number Direction Street Name_ 1 Clt ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) h O EGC - -�C�Vnen Loa, <br /> 1 Street Number O Street Name <br /> CITY STATE ZS, <br /> PHONE #1 Ex . APN # LAND USE APPLICATION # <br /> (2.10i)q LAI JD9t a <br /> PHONER E% . 80S DISTRICT LOCATION CODE <br /> ( ) Ool C l <br /> CONTRACTOR / SERVICE REQUESTOR <br /> R.EQUESTOR CHECK if BILLING ADDRESS <br /> I PH Ex . <br /> BUSINESS NAME I e -'Z <br /> HOME Or MAILING ADDRESS l W N �I/ A F `-Ji_J,l) l�i _ I LA U <br /> /.+ <br /> CITY V'`� W STATE C,nA�_l�(.-BZIP /] -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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, ATE and FE laws. <br /> APPLICANT'S SIGNATURE: �2f�.719 DATE: <br /> PROPERTY / BUSINESS OWNEROPERATOR / MANAGER Or R AUTHORIZED AGENT ❑ <br /> IfAPPLICANT is not the BLLLINGPARTY 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the saPA ]J; <br /> provided to me or my representative. Air <br /> I ry/ n. <br /> TYPE OF SERVICE REQUESTED: A 4p® <br /> COMMENTS: 3 2 18 <br /> SAN JOAQUelvVIR0IN COU <br /> HEgLTN DE 7d 1 Y <br /> T <br /> ACCEPTED BY: EMPLOYEE #: DATE: <br /> ASSIGNED TO: CCCNNN��` EMPLOYEE #: DATE:: e ( '10 <br /> Date Service Completed (if already completed): SERVICECODE: P I E: a �� lg <br /> Fee Amount: . / am�G ( }„j' Amount Pai / Payment Date <br /> D <br /> Payment Type "7 •�J lV Invoice # Check # 4025 Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11/17/2003 <br />