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3 <br /> SAN.JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> VAtA-Nr I <br /> OWNER/OPERATOR V r„, / <br /> d�-`d ,�-Aw&viN,&Tri T(tvs-r CHECK if BILLING ADDRESS <br /> i <br /> FACILITY NAME <br /> Fvwu <br /> S C F I w4 <br /> TAI <br /> SITE ADDRESS <br /> sea-1 <br /> Street Number DIrection Street Name DSC-ift� Zi Co e <br /> HOME or MAILING ADDRESS (if Different from Site Address) t( o W t_f w 000 Q 10 %Ver Buy * ( <br /> Street Number Street Name <br /> CITY ??� 1--o STATE ZIP <br /> CA 95207 i <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# j <br /> (20 ) 2--9559 I ! <br /> PHONE#2 ExT• BIDS DISTRICT LOCATION CODE <br /> 6 ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR y <br /> �eC'f '(�(�♦� CHECK if BILLING ADDRESS <br /> BUSINESS NAME �— PHONE# ExT. <br /> sDr C- ° ef1 9-4K-937� <br /> HOME or MAILING ADDRESS FAX# E <br /> 252 tlrt P4&1C I) cvr Sv,TX SSS I ) 1E <br /> CITY r SAE ZIP '75 833 <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,Standencls,S End FEDE aws. <br /> APPLICANT'S SIGNATURE: ® DATE; J } <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTOf <br /> 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 the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentallsite 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. <br /> i <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />