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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/O/ /PERATOR p <br /> SuS�{ �/ oL K CHECK If BILLING ADDRESS <br /> —TO Iq A <br /> FACILITY NAME <br /> /'OGf� ,eES/D�NC� ,/ <br /> SITE ADDRESS 1,A VIE- OA/< R0.4 STDcKTD.c! �Js24a <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 5A/r/F_ Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> ^0� CSNVPE CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> ao 4oz-165 <br /> HOME or MAILING ADDRESS FAx# <br /> �� 0 13OX 3 7 R (-20g) 0 (-8 z� <br /> CITY u STATE CR ZIP 1a3 ig <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, S E and FED L laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> II <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANAGER ❑ T }d <br /> HER AUTHORIZED AGENT <br /> IfAPPLICAMT is not the BILLINGPARTI;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: — /I Sd/I sm t T. 5 REU/E W <br /> COMMENTS: N✓�NF 316//l REVEL V Et) <br /> ,����/t� 30;►�.��-, ^'�J � 2013 <br /> DEC 0 <br /> AI— <br /> SAN JOA(]UlN COUNTY <br /> ENVIROPARTMENT <br /> ACCEPTED BY: l— � � T EMPLOYEE#: DATE: <br /> ASSIGNED TO: .A ii �CJ EMPLOYEE At: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 5 ) P 1 E: ,Z b .0( <br /> Fee Amount: j Amount Paid Payment Date Ia <br /> Payment Type Invoice# 3� Check# Received By: <br /> EHD 48-02-025 <br /> SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />