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SAN JOAQUI OUNTY ENVIRONMENTAL HEALTH .PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME C�C,�SeI'SCc�� 2-ct <br /> SITE ADDRESS 5-23(_ <br /> 'v` ✓ Street Number Direction Street Name u•^',\ Cit Zi JCodeX� <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT" APN# LAND USE APPLICATION# <br /> (-Zwl) t °17Z4WZ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> �w4(1 Cce S" _CRQ �� r CHECK If BILLING ADDR <br /> BUSINESS NAME l ` 4� c��/c .7C PHONE# EXT. <br /> L 4f 7 3 6 <br /> HOME or MAILING ADDRESS J FAx# <br /> 3 S$7 .v est l i !) `�`Y`- - 177S— <br /> CITY <br /> - /77S— <br /> CITY STATE C ZIP �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 DEPAR'rMENT 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 Cortes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ft-vrii: .Ile?/�7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT' L 6 5e4- ce— <br /> f <br /> If.-I PPL/CANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 iSpw,t,;lable and at the salve time it is <br /> provided to me or my representative. �F'CTNfF�/l <br /> TYPE OF SERVICE REQUESTED: 0 SF " <br /> COMMENTS: N Fyy�40U C=Z <br /> Ih�CN Co M <br /> - D BV <br /> m= O <br /> to <br /> r <br /> ACCEPTED BY: EMPLOYEE#: DATE: }L1_ <br /> ASSIGNED TO: EMPLOYEE#: Z� DATE: I 0-;z- <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount:—T <br /> q5 Amount Pal '�-$11 -f"rr 17.OZ) Payment Date <br /> Payment Type 1 Invoice# Check# 62r?8 Rec ived By: <br /> EHD 48-02-025 e� e rp cry ►e r t �fq �' SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />