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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ��SERrr``VICE REQUEST# <br /> 'I 2--Z—,:5k R's;)S,+C'w v1 U I` U <br /> OWNER/OPERATOR ,� f <br /> I v CHECK If BILLING ADDRESS <br /> FACILITY NAME I/ C (,) S Z <br /> SITE ADDCR�ESS ���� �C � o W D l�� ( HkI L P S-j 30 <br /> 1 1 Street Number Direction Street Name City ZIP Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) f`rj EJ (ZO S � <br /> 03 i�E l��12G L U Street Number Street Name <br /> CITY STATE ZIP <br /> S^A,Z��l Y-0 E yv 7v CA- 9 s"s-Z q <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (c)/(, ) x-1-1- q`'s?o <br /> PHONE#2 EXT, BOS DISTRICT LOCATION CODE <br /> 61 fL ) r �7—%`�& L <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR S _[�(Z� ) CHECK If BILLING ADDRESS <br /> BUSINESS NAME I EXT. <br /> X1'1 ICS Cn� 3 122 A L 1 'TW J Sfi PA69# � ( -W/ 4 <br /> HOME or MAILING ADDRESS 8 3) y1 t--/VD&,T RO S l."J /0 FAX# <br /> n q n/ ( ) <br /> CITY Sf� wl m STgTE ZIP r 2�J <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 /> I <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: Q111rnQ-k� h� DATE: �r —2 2 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is not the BILLING PARTY,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 ald gthe same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: Nov <br /> ?019 <br /> N RDUIM C p�N <br /> STH 0 MENT <br /> EP ftr4f NT <br /> ACCEPTED BY: �S EMPLOYEE M X I DATE: <br /> ASSIGNED TO: EMPLOYEE M ccJJ I DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: E: <br /> Fee Amount: Amount Paid Payment Date l� <br /> Payment TypeInvoice# Check# Rec4ived By: <br /> EHD 48-02-025 (� �1 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> l \` <br />