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t <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1 S <br /> OWNER/OPERATOR J C <br /> 1=F=F 15\j er I - CHECK if BILLING ADDRESS El <br /> FAciuTv NAME <br /> SITEADDRESS gl� IO I PE ZZ (2-0 .17 -5 b( Dr.I ')52-15 <br /> Street Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) PA <br /> Street Number Street Name <br /> CITY AA OpeFsra STATE C4 ZIP 6)5 32-& <br /> PHONE#1/Y` EXT APN# LAND USE APPLICATION# / <br /> lLo�1 - 6777 08°) - 03o-38 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR A, 11/—G �Y <br /> /"` r^ CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT' <br /> D I t �-o►J M U�P�Y 209 33 -(�4-( <br /> HOME Or MAILING ADDRESS0 WX 2-180FAX# <br /> O (?-on) 334-o7z-3 <br /> CITY Loo t STATE Cb ZIP 5Z,4i <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,STATE nd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ HER 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. /J <br /> TYPE OF SERVICE REQUESTED: A' RFC <br /> COMMENTS: NO 0 <br /> /^ V 7ZO <br /> S <br /> (�D q/V Dq <br /> yFq�� 0//V C N S <br /> FPXq q� T l <br /> ACCEPTED BY: EMPLOYEE#: �� DATE: // <br /> ASSIGNED TO: _ EMPLOYEE#: DATE:�� S <br /> Date Service Completed (if already completed): SERVICE CODE: 3/-1 PIE: 0 <br /> Fee Amount: Amount Paid 8 O Payment Date �� QS <br /> Payment Type Invoice# Check# \p Q Received By: �- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />