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r` <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> 1'4. /'atcryECK if I Ess❑ <br /> FACILITY NAME �t <br /> e` /°ae-co L 4:2 j28 <br /> S ADDRESS �C��C� AC 195-j <br /> 4.2— ShNt Number Dlnctlon lel�-( trMt Name C Zf CoO� <br /> HOME or MAILINo ADDRESS (H Different from Site Address) ` 0-v 0"� ` <br /> Strep Number SbW NormC <br /> CITY �- �'"1 � $TATE� ZIP <br /> PHONE#1 ff�\ En. APN 9LAND USE APPLICATION <br /> (SIS► 451 —ZCa�� I 2i Z— <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> /N IV ` CHECK N BILLING ADDRESS WIJ <br /> BUSINESS NAMEL � ' Exr <br /> HOME or MAILImG ADDRESS FAx-ffI <br /> S-Yt O IN ) f 17 <br /> CITY C0* 10 IZESA <br /> STATE 4A LP <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 /> 1 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,STA •RAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ AGER ® 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, 1,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. <br /> TYPE OF SERVICE REaUESTED: Ir <br /> COMMENTS: <br /> CLP 1 t'n la v l L► e- ?? �FQ <br /> CbU <br /> ACCEPTED BY: ' c EMPLOYEE M DATE:ASSIGNEDTO:TO: rQ 55 i t� EMPLOYEE M DATE: <br /> Date Service Completed (N already completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Pa <br /> Payment Date <br /> 579S.0(- y z !.S_, <br /> Payment Type Invoice# Check# Rece ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />