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SAN JOAQUIN 0UNTY ENVIRONMENTAL HEALTHPARTMENT <br /> SERVICE-REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Cqq <br /> OWNER/OPERATOR <br /> /A t '1 J c"I A L)! ` } 6 �A f f(7�L CHECK If BILLING ADDRESS❑ <br /> - <br /> FACILgyNA�IE. .. IAVi(,% ) <br /> SITE ADDRESS '7 r' S ✓/^!*7�- /N m� m��(, <br /> Street Number Direction '/ / Street Name Cit 7 Zi Code <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 /> PHONE#2EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ty{ - sG i3�1<(/1/11&/`y' CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME)V 1 PHONE# EXT, <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 0 i STATE ZIP , <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE:r 2 DATE L <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT IY I 1 ` �` Ga i <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 theAdO <br /> d at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or enviro sessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available aAtU �q eta�U}�(�g11me it is <br /> t' ly <br /> provided to me or my representative. U= n�—F( <br /> SA <br /> TYPE OF SERVICE REQUESTED: C!H,+lp'G� ( (,'� b(r� ��� Nli) rl lQ ENVfIRONPME�N ENI <br /> COMMENTS: vj r� �/I� Cr 014 G jj l�.J' �-1. 1 L S (C l�'Vt � �Pelr �� ®1 1iv / --/-U 4'cr4" <br /> UA,-f-Kbr,4-76&4-76& /,X; A4�- A434- <br /> ACCEPTED BY: L!��C EMPLOYEE M d'13 DATE: £7r i/ f fl <br /> ASSIGNED TO: 1C c �— I ` EMPLOYEE#: CJ(� DATE: !J <br /> Date Service Completed (ifalreadycompleted): SERVICE CODE: Q P P 1 E: oe <br /> Fee Amount: b(d Amount Paid 6 Payment Date g �� C) <br /> Payment Type Invoice# Check# 4 Received By: 'Y � <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />