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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or r perty FACILITY ID# SERVICE REQUEST# <br /> Upoo d bo <br /> OWNER/ PERATO <br /> CHECK If BILLING ADDRESS E] <br /> FACILITY NAME " (4w ..{15� / ___ / <br /> SITE ADDRES N06, f r�}�JVF�Cr`/^Y-(LA./,/ <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY n N�t� STATE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> ( ) , 0? <br /> PHONE#2 ExT BOS DISTRICT LOCATION CODE <br /> �\.v <br /> CONTRA10� CTOR/ SERVICE REQUESTOR <br /> REQUESTO AA CHECK If BILLING ADDRESS <br /> BUSINESS NAME L�S P - 339T <br /> HOME or MAILING ADDRESS (/�(J FA%# <br /> {h aZf/I 46o 5<2 <br /> CITY STATE ZIP Ce; ^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 or <br /> 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 JoAQuRN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT 11 <br /> IfAPPLIC.4NT is not the BILLING PAR TP 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 same time it is <br /> provided to me or my representative. �. <br /> TYPE OF SERVICE REQUESTED: U <br /> COMMENTS: JUNq � <br /> S�� ���t <br /> 4t ON /Vtq <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: AAEMPLOYEE#: DAT . <br /> Date Service Completed (if already completed): SERVICECODE: PIE: ;-;1 <br /> Fee Amount: Amount Paid I Payment Date Z I <br /> Payment Type Invoice# Check# `k� q b 9 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />