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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# EnRVICE REQUEST# <br /> rA 0 0010 e 2 'K ws I'2-4-3 <br /> OWNE i OPERATOR <br /> CHECK If BILLING ADDRESS <br /> 7/ ' <br /> FACILITY NA <br /> SITE ADDRESS 2090 I I�V V/���� MnQ I•l�Y 41 r jJITils-33-4- <br /> Sir <br /> eet Number Direction treat Name 7`, v Ci �" " Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 12 <br /> /'yl, �f� /Weet 5 7` <br /> Sfre�� ber ' ' ' „`� Name <br /> CITY ST E ZIP <br /> dyz 5�3 . <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT, BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTO <br /> 2W <br /> CHECK if BILLING ADDRESS E/ <br /> BUSINESS NAM / / ]'" ,� L- PHONE# -;ZC , `/ XT. <br /> HOME or MAILING ADDRESS �L FAX# <br /> I ( ) <br /> CITY �twSTAT IA 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 application iat the work performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAT nd FE L law . <br /> APPLICANT'S SIGNATURE: < DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT 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 envi ntal/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availab i time it is <br /> provided to me or my representative. C !Lwe <br /> i- WAZO <br /> TYPE OF SERVICE REQUESTED: C w(,r <br /> COMMENTS: ✓p D,9 <br /> FNM CO <br /> �'�G D�A,yR MHT <br /> ACCEPTED BY: �� I/q) I j EMPLOYEE#: DATE: <br /> ASSIGNED TO: S o n • n�Gb 6 EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: 0(01 PIE: I f Irl. <br /> Fee Amount: C�Z Amount Paid 5 `d Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> ��� �clll3 <br />