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SAN JOAQUI60UNTY ENVIRONMENTAL HEALTOPEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (R IE T 4 c c. C, A-S 0 tic.- eA '0 0 d f(�5q S Rov 43 9,-* I <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> v t(L S To 19 lz; C - <br /> FACILITY NAME V 1 I/ �-�0 ,� 3 <br /> SITE ADDRESS lG c �(Z E- A'0S�C C'66 <br /> 66 ,ro 14 9 S-2 0 g- <br /> Z Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) F-rL P►L l S C- S T <br /> S6 '+ Street Number Street Name <br /> CITY r a�E W 0 t�� STATE ^ A ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# `7 <br /> [PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR (CW b ,/a L,�0 <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> t6 3-.3 - /( T2. <br /> HOME or MAILING ADDRESS FAX# <br /> P- 0, aaX /CZr (,'tb ) <br /> CITYf t I ' � ^ ! � � STATE R ZIP p S� p <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authori/zed 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 tha the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE nd EDE laws. <br /> SIGNATURE: (VA� DATE: q A,- <br /> APPLICANT'S /Q <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT -rr 5 T­tM.G Ca.CTQ A�VI-Q� <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 representative. <br /> TYPE OF SERVICE REQUESTED: L A-*( (Z 12-- v t EF,w — (A S 1 ( 6 r–,7- <br /> COMMENTS: �Gtly SF/p <br /> � L 0 # oso�/133 :ate C L�Zoe <br /> ,�,,D SgNJO 7 <br /> 7 Zoos <br /> OS-66/S-6 X--O Lo Z000 N TV/A N/NOO <br /> o;,.S 14 <br /> tioFpMFbTVN2Y <br /> 1 qc <br /> ACCEPTED BY: 6) EMPLOYEE#: 0 -2 ( DATE: r Z 1 S <br /> ASSIGNED TO: -so C(L S EMPLOYEE#: 3-7 3DATE: t /-t f o5 <br /> Date Service Completed (if already completed): SERVICE CODE: �Q PIE: ��. C <br /> Fee Amount: 1 )-:M0() Amount Paid O Payment Date `7 <br /> Payment Type Invoice# Check it Received By: <br /> EHD 48-02-025 SR FORM(Golden Ro ) <br />