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SAN JOACOUNTY ENVIRONMENTAL HEALTH D• <br /> QUIN RTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID N SERVICE REQUEST A <br /> KeAmak <br /> OWNER I OPERATOR <br /> CHECK if BILLING ADDRESS <br /> K cc i 6 e r C� <br /> FAcit try NAME <br /> 1 <br /> SITE ADDRESS S,ItDG.�"'Ir'i F52,10 <br /> 3 Street Number Direction 2tr=1 Ilama Citv 7jp Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> �,_ Street Number Street Name <br /> CITY STATE zip <br /> PHONE Nl EXT- APN# LAND USE APPLICATION# <br /> PHONE k2 EXT BOS DISTRICT .7 LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR C CHECK if BILLING ADDRESS LtO <br /> K. W lift <br /> BUSINESS NAME PHONE A EXT, <br /> Pcetro AMA l� ' S 2[(-C191S' <br /> HOME or MAILING ADDRESS FAX A <br /> P.O. box 23v 1 ( I <br /> CITY O INACI ICA ----- STATE CA <br /> ZIP 91(/ <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 Or <br /> 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,SATand EDER L laws. <br /> APPLICANT'S SIGNATURE: DATE: _ 0 <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR MAN ER I ❑/T OTHER AUTHORIZED AGENT' <br /> If APPLICANT is not the BILLING PARr7,proof of authorization to sign is required Ti r!e <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above <br /> site address,hereby authorize the release of any and all results,geotechnical data andlor environmentalisite assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br /> my representative. <br /> TYPE Of SERVICE REQUESTED: A-t t� <br /> COMMENTS: It I <br /> APR 0��FD <br /> SAN JOA ?11!3 <br /> Qv <br /> HEAL it C) <br /> ACCEPTED BY: - n <br /> DATE: /i ' <br /> ASSIGNED TO: iZ +&UAW DATE: 'T <br /> Date Service Completed (if already completed): VICE CODE: (1 PIE: <br /> lo <br /> Fee Amount: r O0 Amount Paid Payment Date b .3 <br /> Payment Type Invoice# Check# 6 1 Ree Ived By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07!17108 <br />