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f . <br /> r <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS //d D S. n7�tl/V S'T. N <br /> rn i 1H S <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> //&'b S .4 Street Number Street Name <br /> CITY <br /> m l�NTFCA scA .P P-5­3 3 <br /> PHONE#1 EXT77 API# LAND USE APPLICATION# <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORx /A <br /> S,9 C HA L L) <br /> -J CHECK if BILLING ADDRESS <br /> BUSINESS NAME �¢ PJTR tC f}9 CD M PIn PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY ,.yl 19-1%ol •T4�7—Ci4 STATE ZIP 9 -5-337 <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: a�.1�4 DA'rE: <br /> PROPERTY/BUSINESS OWNER 2f OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PAR71 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 COUN"rY 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 REQUESTED: US /. R�� TO F1 r PECENPA ED <br /> COMMENTS: [ 211 <br /> APR - J <br /> SAENVIRONMENTAL ITY <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: LCI&)C_ EMPLOYEE#: ��IJ.S� DATE: <br /> ASSIGNED TO: /1/119 t/ EMPLOYEE#: Z 7 C, DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: % P/E: _ <br /> Fee Amount: � 6,6,OU Amount Paid 3 LL 0 Payment Date s <br /> Payment Type Invoice# Check# SID Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />