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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> f -- Tt7e,645SI OL^rri S i2 oa-413 '9 (0 <br /> OWNER 1 OPERATOR <br /> ]N. WA !VAJE S ./ L L terG1,/ ' ev, L C CHECK If BILLING ADDRESS D <br /> FACILITY N � INTS � 1 a.0� <br /> SITE ADDRESS G y(1406;3A 7 qFZI <br /> Z <br /> Street Number Direction 7 Street Na e C Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> T' C Q Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1T <br /> ( ) APN <br /> ND USE APPLICATION <br /> _� <br /> S -D/ R <br /> PHONE#2 FXT• BOS DISTRICT LOCAp�oo��CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> k REQUESTOR <br /> rJ t CHECK a BILLING ADDRESS <br /> IT <br /> BUSINESS NAME 0 A! G T � r PHONE# ExT• <br /> 1Y.7 V4 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 4-49 STATE ZIP <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 HEAT TH.DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> 4 <br /> I also certify that 1 have prepared this applicattIal and that the rk to be performed will be done in"accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STAT FE�ERA <br /> APPLICANT'S SIGNATURE: DATE: 3 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER LITHORIZE.AGENT <br /> If APPLICANT is not the BILLING PAR 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. <br /> TYPE OF SERVICE REQUESTED: Al/r tV S D 1F111 EK/ N� <br /> COMMENTS: <br /> a /Ulea <br /> PA <br /> 4 V <br /> ACCEPTED BY: Q�IV��I EMPLOYEE#: 3 Z 1 DATE: O 3_ <br /> ASSIGNED TO: %-. M D�� EMPLOYEE#: 15-8&(� DATE: d 3 <br /> a a� <br /> Date Service Completed (if already completed): SERVICE CODE: ,C-�5 P i E: <br /> Fee Amount: 46-6-0& Amount Paid / Payment Date h c; <br /> Payment Type Invoicle# { Check# '(47Rec ived By: <br /> EHD 48-02-025 <br /> REVISED 11/1712003 / 1 SR FORM(Golden Rod) <br />