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SAN JOAQUI. OUNTY ENVIRONMENTAL HEALTH 2ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> A ;�A�TLC1t4 �6/v S �c�-t Zt 8 Utz <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Ave-C) i <br /> SITE ADDRESS i✓I I 1 (_ �buf' `(,Cal �L't(16— S 46- <br /> Street <br /> CStreet Number I Direction Street Name ty Zin Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR � C.W,W, <br /> L` CHECK if BILLING ADDRESS I� <br /> BUSINESS NAME PHON # EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> � �0 U�,tLvl Avc- (q6 t) C - <br /> CITY C ao- Ac' <br /> STATE C q ZIP Cj c /, a. <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operatoror 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 FEDERAL laws. <br /> � <br /> 7CGAPPLICANT'S SIGNATURE:' �' DATE <br /> PROPERTY/BUSINESS OWNER 1:1 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT� CG� Z(t_"k- 6..". .. . . <br /> 1^ <br /> IfAPPLICANT <br /> 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 environmentaUsite 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. p <br /> TYPE OF SERVICE REQUESTED: i VL ' o C Acv( :r L t t k'S'' t�('L+Lmt�(L*- d9 �� y <br /> COMMENTS: <'-" t U r L1.6 X �✓� T6�f L C� E F 1 RE iV E <br /> _v_ 06 <br /> SU 12 <br /> SAN JOAQUtN C NN <br /> VIFiONMEN EI.II <br /> ACCEPTED BY: EMPLOYEE#: z DATE: i <br /> ASSIGNED TO: EMPLOYEE#: l/ DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: L7 PIE: <br /> Fee Amount: Amount Paid 1'TS 0 C) Paymen Date ( c) L <br /> Payment Type t/ Invoice# Check# `Z2 Received By: <br /> EHD 48-02-025 SR FORM(Golden Ro <br /> REVISED 11/17/2003 <br />