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�. 2-01 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST. <br />Type Business or Property FACILITY ID # SERVICE REQUEST # <br />-F-A 000 o %i _ C0 5'g o0R <br />OWNER / OPERATOR <br />THof)Pe GI 1 CHECK if BILLIN_ G A_ DD_ RESSE] <br />SITE ADDRESS A, <br />1`N °1`�C11'aVl <br />' Street Number DireetionStreet Na � � � � - Ci � -- <br />HOME Or MMUNG ADDRESS (If Different from Site Address)' . Z, code <br />Street Number Street Name <br />CrrY <br />STATE .. ZIP <br />'PHONE #i Exr. <br />.. . APN #. LAND .USE APPUCATION# - - <br />PHONE#2 Exr. BOS DISTRICT <br />( 1 LOCATION CODE <br />CON TRACTOR"% SERVICE REQUESTOR <br />REQUESTOR ' <br />CHECK If BILUNG ADDRESS 0 <br />BUSINESS.NAmE <br />PHONE 7 Exr. <br />HOME orMAIUNG ADDRESS <br />FAX# <br />CITY <br />STATE . zip <br />9 <br />BILLING AGKNOEDGEMENT; I, the undersigned. property. or business owner., operator. or authorized agent of same, <br />aclmowledge that allsite and/or project specific EN.ViRONMENTAL HEALTH DEPARTMENT hourly charges. associated with this project <br />oractivity will be billed to we or in 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: DATE: -&L -g - nq <br />PROPERTY / BUSIIVESS OW,YERD OPERATOR/ MANAGER 0 OTHER.AUTHOR=D AGENT <br />Lf�P C Tis not the &LUNG P.4 proof of authorization to sign is required Tile <br />AUTHORIZATION TO RELEASE M ORIMATION: When applicable; I, the owner or operator of the,property located at the <br />above .site address, hereby authorize the release; of any .and• afl results; .geotechnical data and/or environmental/site assessment <br />information to the SAx.Jop,QUW COUNTY.ENVMONMENTAL HEALTH DEPARTmENT.as soon as itis available and at the same time it is <br />provided tome or my representative: . <br />TYPE OF SERVICE.REQUESTED: <br />cabMENrs: s to <br />- — .. -... <br />- 09 <br />0 <br />D 60- <br />SAN J� R0tAN G��� <br />E S <br />pEP� E <br />N <br />N � <br />ACCkW 1 6 <br />MPLOYEE #: C DATE:. lZ <br />ASSIGNED TO: _ t EMPLOYEE #' . ` DATE[ C <br />_': <br />Date Service Completed (If already comp ted): <br />SERVILE CODE. P / E: <br />t=ee Amount: c� Q � <br />Amount Paid {{ .Pa int Date <br />Payment Type r <br />Ym yPe ✓ Invoice # <br />heck # <br />V <br />C . Received By: <br />` .EHD•I "2-025. <br />REVISED 11/77/2003 SR FORM (Golden Rod) <br />