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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> cup u VC' <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> O ER /-"IV49 i!!Z-4 STiza L G/h9 E <br /> FACILITY NAME <br /> .T S 2E NGf! q <br /> SITE ADDRESS SOL f} STOC lCrOl\I ( SLI <br /> 17 3 Street Number Direction Street Name Citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> :C 3 i v <br /> PHONE#'I EXT. <br /> APN# LAND USE APPLICATION# <br /> �20 <br /> el64�75 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR T <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> (4d <br /> HOME Or MAILING ADDRESS O x FAX# <br /> ( ) 669-Z s <br /> CITY L O� STATE C't ZIP / <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 appl' tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, S T.and FED laws. <br /> APPLICANT'S SIGNATURE: DATE:: <br /> R <br /> PROPERTY/BUSINESS OWNER❑ OPEATOR/ NAGER ❑ THER AUTHORIZED AGENT E <br /> If APPLICANT is not the BILLING PARTY proof of au OriZation 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. n <br /> TYPE OF SERVICE REQUESTED: (,9 LSU/r,4 t31 LIT S-7'U a 6✓/6V/ — f�F J (-I--E <br /> COMMENTS: <br /> N O V 9 2004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: p LI V,£, e'4 EMPLOYEE#: O 3 2' DATE: // q <br /> ASSIGNED TO: e-f- t j t� r .--a•= EMPLOYEE#: 0 3 z DATE: c) <br /> � 0 <br /> Date Service Comple d , ' alread completed): SERVICE CODE: SZ Z 9zy p/E; O <br /> Fee Amount: _ y/1��� Amount Paid �2 7 C Payment Date <br /> Payment Type Invoice# Check#a�5- <br /> Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />