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SAN JOAQT 7OUNTY ENVIRONMENTAL HEAL- EPARTMENT <br /> SERVICE REQUEST <br /> 4 Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 3os 14 SSS <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> (L�-q _�s I <br /> FACILITY NAME J54 1_' Q� <br /> SITE ADDRESS �, K Irl-ZA4 ,--) / O D' � S Z�Z. <br /> `'T Sr Street Number Direction Street Name F• city Zip Code <br /> HOME or2MAILLIINNGG ADDRESS (if Different from Site Address) <br /> W—5 , 39{/, '('t"- C, % 0/ Street Number Street Name <br /> CITY STATE b� ZIP <br /> 'duU iZ K) <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (J8.3)18,?& - 7v6 (Ds C;- �l <br /> PHONE G EXT. BOS DISTRICT LOCATJON CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR - CHECK If BILLING ADDRESS <br /> ty <br /> �gr)71T Z, <br /> BUSINESS NAMEPHONE# EXT. <br /> S4f ( T1 <br /> HOME or MAILING ADDRESS 2 Z u 9/.Z�% ' A-�/V L ,t FAX# <br /> z 'Gt, (7b 7)5 v5 S 15 <br /> CITY 4/17_4 <br /> /) STATE /44 ZIP <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 /> 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,Standards,STATE and FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: DATE: &_'9y_<aey <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT 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,,and at the same time it is <br /> provided to me or my representative. 'nn <br /> TYPE OF SERVICE REQUESTED: �,( S T 12 <br /> COMMENTS: 2 <br /> s � 2Qp8 <br /> do Nt TH ONME <br /> NTUNTyNTy <br /> 4EpART�y NT <br /> ACCEPTED BY: C) ` `jE,t Q- EMPLOYEE#: Z DATE: <br /> ASSIGNED TO: Q C EMPLOYEE M DATE: �f6 <br /> Date Service Completed (if already completed): SERVICE CODE: / P I : Z3C., <br /> Fee Amount: 4 . <br /> cl l f } Amount Paid . Payment Date IZ4R Ll <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />