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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICEE T# <br /> �- S 421a� V R-X b 56 � 15K___ �I' (; <br /> OWNER/OPERATOR <br /> I r / r��/ �r►"�„// /�/'�n// J / � CHECK If BILLINGADDRESSE] <br /> FACILITY NAME <br /> SITEADDRESS 2.;141S 1-Cxr-r6E/n1-)Af I,�;Z4Z <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different fr/o/m�Siitte Address) <br /> C/(� Street Number Street Name <br /> CITY ! Gt / Q/V f 0 STATE ZIP 7�-Z <br /> ,51 <br /> PHONE#1 i\1ExTT. APN## LAND USE APPLICATION# <br /> " ) 256 1 6 5a1 qbO I <br /> P�O)�� /��� EXT. BOS DISTRICT LOC�ApTION CODE <br /> V�- <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR � _ / <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPH NE# EXT. <br /> �P � `/�JZ Z10 6Z6- �-l132 <br /> HOME or MAILING AbDRESS FAX# <br /> /�ID�'I �wao�!` ter!✓; x -Ll,' ( ) <br /> CITY _ / t7 , !`6 STATE �(� v ZIP 7Q 25; <br /> BILLING ACKNOWLEDGEMENT: 1, 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,Standards,STATE and F ' 1` aws. C q <br /> APPLICANT'S SIGNATURE: // DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT A <br /> /f APPLICANT is not the B1LL1N�RTY,proof of authorization to sign is required T#F4FkYMENT <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the proR&Mveoe <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 a(4FS#�tilnt9 is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: �dG C07�6 ENVIRONMENTAL <br /> COMMENTS: <br /> 4 G1,4,rV� c r o w&/�--iz,S-!f 0ccST SAS 97AW 011 ADD 1 L t T�©rlZ <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: ` –Z— EMPLOYEE#: DATE: _5 - <br /> Date Service Completed (if already completed): SERVICE CODE: I P 1 E: 161 v Z <br /> Fee Amount: 1�Z Amount Paid `5 2- <br /> Payment <br /> — Payment Date 3 l <br /> Payment Type Invoice# Check# cv Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 �. <br /> �Q-otc�c?253 <br />