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SAN JOAQUINO r'O NTY ENVIRONMENTAL HEALTH"EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property -p FACILITY ID# SERVICE REQUEST# <br /> a 7 15�' FCO3'?0 _77 <br /> �FJD 3 <br /> OWNER/OPWATOR L 0 <br /> NCHECK If BILLING ADDRESS� <br /> FACILITY NAME <br /> Op <br /> SITE ADDRE 12 so f-\. c's- <br /> -treetN--m4 Direction Street Name 1 City Zip Code <br /> HOME or M (If Different from Site Address) <br /> � Cecl�erpat:�1-�. (Jr. <br /> Street Number Street Name <br /> CITY bc, STATE ZIP ra � Ca. <br /> P ONE#1 Exr. APN# LAND USE APPLICATION# <br /> o9) X16 s 535 <br /> PHONE#2 Exr• BOS DISTRICT LOCATION CODE <br /> o-) b3 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESSr c' <br /> BUSINESS NAME �) PHONE# EXT. <br /> L 1 � � e- 1 Ct���' t`c- C�o: 1n 0 \'_ - 633 <br /> HOME Or MAILING ADDRESS FAX <br /> CY-1 1 y61 -b3ti <br /> CITY STAT Zip <br /> ZIP Cl',�1 <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 JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: W tu— DATE: 5- 1 —7 <br /> PROPERTY/BUsINESSOWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTA <br /> If APPLICANT is Ot a BILLING PARTY proof of authorization to Sign is required Title <br /> AUTHORIZATION`TO RELEASE INFORMATION: When applicable, 1, 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: &if 0/7� RECEIVED <br /> COMMENTS: x700 A <br /> Y <br /> MAY 18 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: Jam' <br /> ASSIGNED TO: EMPLOYEE#: JI DATE: <br /> Date Service Completed (if already Completed): SERVICECODE: Iq PIE: <br /> FeeAmount:4L4 3q. 61D Amount Paid 0,? 79 a a Payment Date <br /> Payment Type ✓ Invoice.# Check# S4 t(3 Received By: <br /> EHD 48-02-025 - SR FORM(Golden Rod) <br /> REVISED 11/17/2003 - - <br />