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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> sLywol U11039 <br /> OWNER/OPERATOR fog <br /> CHECK If BILLING ADDRESS <br /> CILrrY NAM r' �_ <br /> SITE ADD SS 111 /��( n �� V� Qom` �-� - Pll,�­10� <br /> Street Nu mmbor Dirccllon " Vc, Street Name ' `\I Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) /_C,�-- 109`p, , U OGI A v ro <br /> l0 <br /> Street NumberI <br /> W W S_tree[Namve\ <br /> CITY d CIA STATE ZIP 19 <br /> PHONE#'l ExT• APN# LAND USE APPLICATION# <br /> (Zoff) 475 <br /> PHONE#1 Exr• BOS DISTRICTLOCATION CODE <br /> _(7 1017) � � - 0 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR mu <br /> ATom <br /> CHECK if BILLING ADDRESS <br /> BUSINESor MAILING ADS NAME � ^ pNSE# L4��- I� � Ext. <br /> HOME RESS FAX# <br /> s w <br /> CITY STATE Zip 9520-7 <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 JOAQUIN <br /> COUNTY Ordinance Codes,Slundarde,STATE and FF.IIE.R <br /> APPLICANT'S SIGNATURE: DATF: ILI 11 <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT JO�2OLI SfI Ut(j_ C401,4•(iY <br /> If APPLICANT is not the BILLING i'.IRT)'.proof of authorization to sign is required Title 9 <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 DFPARTMENT as soon as it is available and at the Same tiny` <br /> provided to me or my representative. I�rM� <br /> TYPE OF SERVICE REQUESTED: {'I�J G I I �V�1 <br /> COMMENTS: New SUCe, <br /> y FMF/R Qv�N <br /> TjyD 4 MUNTY <br /> AL <br /> ENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed: SERVICE CODE: D P i E: <br /> Fee Amount: I�Z Amount Paid t� /�a+ Payment Date <br /> Payment Type r Invoice# Check# Receily d By: <br /> EHD <br /> REVISED 1017/200 3 it I I O 1�� D SR FORM(Golden Rod) <br />