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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FF, ID N-CIAL- <br /> OWNERI OPERATOR �1 _ CHECK If BILLING ADDRESS❑ <br /> HS <br /> FAcanY NAME <br /> SITE ADDRESS 12(o D S'fw fI'(��DE rLD LG D l C1�Z Kb <br /> Z{ C*de <br /> Street Number Oiredion <br /> Street Name C' <br /> HOME or MAILING ADDRESS (If Different from ZIP V Site Address) <br /> `o.• Goy- � L.+ Street NumEer Street Name <br /> STATE I <br /> CITY5-fvCit, TO C04 <br /> r�r) 11APN# LAND USE APPLICATION# Q _ <br /> PHONE#i D I - N0 -O e <br /> acxi 2 3 — (o L fl v <br /> PHONE <br /> �� Exr BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTORI i ` / r 63 O n CHECK if BILLING ADDRESS <br /> V, N (i K�VY PHONE# Ex*. <br /> BUSINESS NAME � N 11 A 02-PL,� <br /> 1W Irl {�e''I FAX# <br /> HOME Or MAILING ADDRESS (��• n �� <br /> CITY / STATE ZIP qS2 �t I <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 JOAQu1N <br /> COUNTY Ordinance Codes,Standards,STATE and £DERAL laws. ^J { <br /> APPLICANT'S SIGNATURE: L DATE: 7 I��cOJ <br /> PROPERTY/BUSINESS OWNERD OPERATOR/MANAGER D OTHERAUTHORIZEDAGENTJR _ <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 Sam,et IltllGl A <br /> provided to me or my representative. ppl-/ , (�,ty G <br /> TYPE OF SERVICE REQUESTED: 5Q 1 L6 S U I'r q I L' l V 5T U DY 05 <br /> COMMENTS: 11 <br /> `(� <br /> Vc�ug+-�/ SuBmIT'rl�L 1 6E �U ��f- <br /> NJRD.EPAR pSO- ME <br /> S <br /> HEPLTt <br /> 30 <br /> ACCEPTED BY: <br /> EMPLOYEE#: � ' DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: - G Z P I E: <br /> Fee Amount: Amount Paid -637a_ 0 Payment Date 3 y OS <br /> Payment Type ✓ Invoice# Check# L110 D Received By: <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 <br />