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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property <br /> FACILITY ID# =SERVICIE REQUEST# <br /> o000 'D� 1 J Z <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> FACILI NAME <br /> Lv �5 \V Sir UC t r 1 <br /> SITE ADDRESS y, L U U r 01 S 3 H v <br /> (7 <br /> T <br /> vc p (7 Kee o !,r� Cit ZI CodeNumberDirection <br /> Street Name <br /> HOME or MAILING ADDRESS (If Different from Site Address) /�� C <br /> "T Street Number I(' �fyStreet Name <br /> STC A ZIP <br /> CITY CA S•Z I U <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT/ LOCATION CODE <br /> CJ f 1 6 �-- <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REClUPSTORAA <br /> CHECK if BILLING ADDRESS❑ <br /> PHONE# Exr. <br /> SS ESS NAME <br /> !121411N! <br /> I2^ \ <br /> Bl) <br /> Lf r v r <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY K \ <br /> STATE �. ZIP C1 S '2— \ V <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 hat the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STA''E nd FE ERAL laws. <br /> APPLICANT'S SIGNATURE.; DATE: a Gl <br /> PROPERTY/BUSINESS OWNEOPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is not the BILLL\IG 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 and at the a It is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> �6 con'St'c� <br /> COMMENTS: <br /> 0 0 ?019 <br /> oC,T LJtl'E( ✓ <br /> � H Enn tRQJJI c <br /> �CTy ( M�OIJN <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: CA <br /> I c . 19 <br /> ASSIGNED TO: h 0�L EMPLOYEE#: DATE: 1 _ 1 <br /> Date Service Completed (if already completed): SERVICE CODE: I P 1 E: ,0 2— <br /> Fee <br /> Fee Amount: G- -Zb� Amount Pai /Q.d Payment Date <br /> Payment Type ' ;` Invoice# Check# Receiv d By: <br /> DA <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> S <br />