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SAN JOAQUIN '"bUNTY ENVIRONMENTAL HEALTH T)EPARTMENT <br /> SERVICI REQUEST -- <br /> Type of Business or Property FACILITY ID# SERV CE REQUEST# <br /> 5 K(I �)3351 <br /> OWNER/OPERATOR _ <br /> 10 JVD M V a-P CHECK If BILLING ADDRESS El <br /> FACILITY NAME 1 <br /> SITE ADDRESS nn n �1 �y <br /> 5�� l /�N t✓L C'"l !��•/ �"A i1 M fin/C JI//J <br /> Street Number Direction Street Name / /Tcity Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) O P"'n Zgci <br /> Street Number Street Name <br /> CITY STATE � ZIP 2 9 � <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (%-C'1 ) - 53 -7 c) oy - Z�� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> �'',�A <br /> 1 k�-C- -� CHECK If BILLING ADDRESS <br /> BUSINESS NAME (->l (—L-" �J n Ql PHEXT. <br /> �� 3 3 � `/ 6 Q <br /> HOME Or MAILING ADDRESS Y FAX# l' <br /> 2lc., ( zjA ) 734--0-7Z3 <br /> CITY i ,l�\ STATE ZIP 9 -2-4( <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. <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 and FEDERAL laws. <br /> S / — OJi <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ BATOR/MANAGER ❑ OTHER 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. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> j/ A <br /> MAS 1 6 200 <br /> N,OA�,UINEo ANN <br /> SA VIPONM T ANT <br /> ACCEPTED BY: EMPLOYEE#: <br /> ASSIGNED TO: r ( EMPLOYEE#: (�Y�/� C DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 7 P 1 E: � <br /> Fee Amount: j Amount Paid3 Payment Date` <br /> Payment Type ` S Invoice# Check# 6-77Z C 4Ijp�1 Received By: Z,,fZ <br /> � <br /> EFiD 48-02-025 5 ` o �� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />