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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Ty of Business or Prop rty FACE ID SERVICE REQUEST# <br /> s,WP-A T <br /> OWN„FR/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> U S OFFCE t <br /> FACILITY NAME 71 <br /> 3UG 'c�S <br /> SITE ADDRESS S NATE I{w� C1t9,E 16T F-P-W tfl01E-- I� 15-(OCI.<ToYl 95 2-A CS <br /> Street Number Direction Street Name C Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 24 D1 U rA H Ne;mu@ c>ovm MS 51�'. 5—�I <br /> Street Number treat Name <br /> CITY STT LE STATE ^ ZIP 3 <br /> PHONE#1 ExT APN# LAND USE APPLICATION# <br /> l2W ) �374 I 1 GI 2 (o O <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> E UES OR //� _ <br /> CHECK if BILLING ADDRESS <br /> BUSINES6 NAME PHONE# ExT. <br /> A[.c•�r o PSH I`��`T� N �3 9 s�- �9� <br /> HOME or MAILING ADDRESS FAX# <br /> SFSSZ6 wl LS 1-1.1p-C- G I.v 57E. Zo 6 (32-3) S4-%I(, <br /> CITY v STATE(`i „ ZIP 190013& <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 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,Standp?c6—,S­TA-'rEand FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: L I s Is <br /> ❑ <br /> PROPERTY/BUSINESS OWNEROPERATOR/MAN 13nnC>GER OTHER AUTHORIZED AGENT Of57UDIC) T' f S7E <br /> If APPLICANT is not the BILLING PARTY proojojautitoriZation 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 timis <br /> provided to me or my representative. N �e <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> 'LII✓ S <br /> y�Tyo N�ti�o <br /> ACCEPTED BY: eA_f f\, EMPLOYEE#: DATE: L' 1 <; -�S <br /> ASSIGNED TO: �� y` EMPLOYEE#: DATE:C <br /> Date Service Complete (if already completed): SERVICE CODE: - P I E: <br /> Fee Amount: Amount Pai &�dZ:) I Payment Date 5 <br /> Payment Type _ Invoice# Ch k# 7 SQ�79 ecei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />