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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 2 <br /> a� � <br /> OWNER/.OPERATOR MdQ y�az E CHECK If BILLING ADORES <br /> FACILITY NAME <br /> SITE ADDRESS / ( Aare P1> L fNo&m `35236 O <br /> Street Number DIMCUon Street Nae C Zi Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) P i3ax 126 <br /> Street Number Street Name <br /> CITY 4.INaE4 STATE r-4ZIP �y SZ3 <br /> PHONE#1 APN# LAND USE APPLICATION# 7 <br /> q, k D6� /50 r02i /ai4 —/o,. Z?� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR � <br /> REQUES70R �`KC CHECK If BILLING ADDRESS <br /> BUSINESS NAME /11L�� C m(I��ff PHONE# g3 6�/3 <br /> HomE or MAILING ADDRSSS / FAX# <br /> . 0 BaX Z1490 [zo ) 3 -n7Z3 ` <br /> A <br /> CITY �Q/ STATE ( ZIP ?'r-2 <br /> d/ <br /> R LLING 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 1 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: <br /> PROPERTY/BtismBss 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, 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. 44 <br /> TYPE OF SERVICE REQUESTED: Y Lt/ <br /> COMMENTS: ba RECENED6TO <br /> If (o ?-b , <br /> JVJ% 16 203 w� <br /> 1' u J0AQU4N COU[+1T1 <br /> SA.CN�I-VIRbNM>=N��- 0 Qv. <br /> ACCEPTED BY: l0 , EMIaL@YE 114 DATE: <br /> ASSIGNED TO: c R �5 EMPLOYEE#: 73!5'�I DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: � IE: v <br /> Fee Amount: t1il05 Amount Paid Payment Date 14 <br /> Payment Type ,/ Invoice# Check# 6 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />