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SAN JOAQU: OUNTY ENVIRONMENTAL HEALTH 'ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> COW�yv.e� < �a ` Sery Ca. '�k-lcln 2a (g c) 2-O ?o <br /> OWNER/OPERATOR <br /> n A K C Q CHECK H BILLING ADDRESS <br /> FACILITY NAME l3 l �` (l C 0 tl 6 0 2- 0 <br /> SITE ADDRESS Ko CS e►►,t to I ve rx Q e-- 0—rife-C-a q5 3 3 G <br /> Street Number I Direction Street Name I Zia Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr. APN* LAND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> 4(- CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> �R t c V. INS a�-}e-s G-�� ►���-.^�� <br /> � PHONE# ExT' <br /> BUSINESS NAME c��a d ►s o I'►1��I�•�,..�� �-� =ofc . 51 1 <br /> HOME or MAILING ADDRESSFAX# <br /> (5- 0) �(� — g39c� <br /> CITY S� Led.f C STATE C 0+ ZIP 9 y S <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,Standards7SE1an/d FEDERAL law . <br /> APPLICANT'S SIGNATURE: V, DATE: — 8 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGE ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT 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 environmental/site 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 %resentative. <br /> TYPE OF SERVICE REQ Y M EN 1 <br /> COMMENTS: REC <br /> EIVtL- <br /> JuN 4 200$ <br /> SAN JOAQUIN COUNTY <br /> ENVIRNTAL <br /> nEPARTM T <br /> ACCEPTED BY: L1 EMPLOYEE#: ai LIZ, <br /> DATE: <br /> ASSIGNED TO: V EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: <br /> Fee Amount: (/a Amount Paid gp14 Lf0'�D Payment Date l l f Q <br /> t <br /> Payment Type ✓ Invoice# Check# if57 Received By: _. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> ♦ f <br />