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SAN JOAQUT 7OUNTY ENVIRONMENTAL HEALT )EPARTMENT <br /> 1-01 SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Pfi- 57-u/RE rz 616E^f7-1 ` C�7 1 0C�z(a <br /> OWNER/ OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME I/ , / <br /> SITE ADDRESS SO u Tia/ �jT�W 4 V�'V &6E <br /> -76,'V 3 Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CIN STATE ZIP <br /> PHONE#i EXT. APN# LAND USE APPLICATION# <br /> ( ) 133 - 9a r%' - oo- o 3 e <br /> Z4 - - o6;�/ <br /> PHONE#2 E)cT• BOS DISTRICT LOCATION IDE <br /> r <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Deg <br /> N <br /> _ / CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# �' <br /> - o <br /> HOME Or MAILING ADDRESS3 `/TF/ (�# ) <br /> CIN 2 STATE CA ZIP 9115 <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 ;3 <br /> I also certify that I have prepared this applic on and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST and FEDEy6q laws. / <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/NFANAGER ❑ XTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of atoorization 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: <br /> COMMENTS: 6 cot, --UFIVED <br /> JUN 9 2005 <br /> SAN JOACUIN COUNTY <br /> �' ✓►"�'�� ENVIRONMENTAL <br /> HPALTH DEPARTMENT <br /> ACCEPTED BY: O L f v�C( 0-0 +4 EMPLOYEE#: 0 3 ( DATE: <br /> ASSIGNED TO: �(4 {T ,�5 EMPLOYEE#: DATE: (-, q C� <br /> Date Service Completed (if already completed): SERVICE CODE: SZ jyf� 2_ P/E: <br /> Fee AmountX 1 ,S U0 J V Z _ rj Amount Paid � ,N� D Payment Da <br /> Payment Type Invoice# Check# a Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) _ <br /> REVISED 11/17/2003 <br />