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SAN JOAQUIN COUNTY ENVIRONMENTALHEALTHUEPAR1MEN'1 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S KD-0 � b 3)29 <br /> OWNER/ OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITEADDRESS � j9�r L <br /> j9 Q �YBn 7 Live .G> T a` <br /> S reef Number Direction Street Name I Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Eur. APN# LAND USAPPLICATit ON# <br /> ( ) coq-(� ?v-z; `f >�� - c (�0O l`F <br /> PHONE#2 Ea . BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ` CHECK If BILLING ADDRESS <br /> BUSINESS NAMPHONE# UT. <br /> E r lr <br /> HOME or MAILING ADDRESS FA%# <br /> CG; O '7Y7" J G <br /> � <br /> CRYG ! /y /, STA7E Zip 04- <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 or <br /> 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,STA and F law^ <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ ERATOR/MANAGER ❑ OTnF.R 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. <br /> TYPE OF SERVICE REQUESTED: �Lk W-FAC-E <br /> COMMENTS: 5 -Ip-A <br /> ACCEPTED BY: OLi U£,I,?A EMPLOYEE#: n 3 2-( DATE: ( 0 0 <br /> ASSIGNEDTO: AS tU0v Lf.,-0S EMPLOYEE#: (f0�� DATE: 4( co�o.i <br /> Date Service Completed (if already completed): SERVICE CODE: 3 /S PIE: _-26_Q3 <br /> Fee Amount: (� .L,� Amount Paid Payment Date <br /> Payment Type Invoice# Check#B .3 pf. Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />