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SAN JOAQUIN OUNTY ENVIRONMENTAL HEALTHEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# <br /> 4 %-5- Z/�t/G �i✓�%/GI7Y SERVICE REQUEST# <br /> OWNER/OPERATOR 0ecQ C /� // � o <br /> Jr- <br /> FACILITY NAME S <br /> �U / 0 ��/aw �/T� CHECK If BILLING ADDRESS <br /> SITEADDRESS 32 Sd <br /> Street Number Direction <br /> HOME Or MAILING ADDRESS (If Different from Site Address) Street Name a <br /> Zi DUGe <br /> CITY Sheet Number <br /> cc // ,, Skeet Name <br /> STATE '.57 ZIP <br /> PHONE#1 En. <br /> 9 APN# LAND USE APPLICATION# <br /> ly�� gz�-9 00 <br /> PHONE#2 Exr. <br /> ( I ENDS DISTRICT LOCATION CODE <br /> REQUESTOR <br /> CONTRACTOR/SERVICE REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BDSINESS NAME GPHONE# En.z� z <br /> HOME or MAILING ADDRESS Feu# <br /> SZ8/ ���?a✓l .cGTf✓ tel/ 17/� Sz,3- 78ga <br /> CITY STATE zip <br /> BILLING ACKNOWLEDGEMENT: 1, 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 1 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: DATE: 4)9 <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED.AGENT 07 <br /> IjAPPLICANT is not the BILLING PAR Tr 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 REQQUUEESSTEED::/ <br /> COMMENTS: d5EZ�I1�O��Y D ��� <br /> APR2 3�2,L000'9^ <br /> ACCEPTED BY: EMPLOYEE#: ^r�N ME t'TIEf1LTH <br /> ASSIGNED TO: EMPLOYEE#: <br /> Date Service Completed (if already complete6): SERVICE CODE: lal P/E: <br /> Fee Amount: Amount Paid `63 5 l7 O Payment ate 14 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />