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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTHOPARTMENT <br /> SERVICE REQUEST \ <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> A rv"/P rn Z'� C,.-S -�) <br /> OWNER I OPERATOR <br /> K/ <br /> r � CHECK If BILLING ADDRESS <br /> FACILITY NAME 1 Ill ` <br /> CorVew\ eV1Ce <br /> SITE ADDRESS <br /> 2(t 3 ' --► o T F c� `� <br /> freet Number Direction Street Name it Zip 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 /> 12 ) 2-3c) - ?, 7'-7?- <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORr� �� C r C CHECKIfBILLING DDRESS� <br /> t BUSINESS NAME ` P <br /> HONE Ev' <br /> HOME or MAILING ADDRESS <br /> CITY rv� b c I STATE ZIP ��o �T"q �'l=. S--,) <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 a that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE an ERAL laws. <br /> APPLICANT'S SIGNATURE: � DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERA O MANAGER ❑ OTHER AUTHORIZED AGENT 1 ®I.J1rlV-5 �CrirjV►�� <br /> IfAPPLICANT is not the BILL G PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 avail ble and at the same time it is <br /> provided to me or my representative. Y� <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: � ' /� � CiL I - •�''� n P 2 9 200p <br /> ba <br /> b ���ONW CQUNTY <br /> HFA1.Ty DE AR M�EMI' <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: '' DATE: <br /> te . <br /> Date Service Completed (if already CompleSERVICE CODE: v PIE: <br /> Fee Amount: tJd Amount Paid Payment 6ate ! IA1�Lz9 <br /> Payment Type Invoice# $ 3 Check# eceived By: <br /> EHD 48-02-025 2 C� (,A' SR FORM(Golden Rod) <br /> REVISED 11/17/2003 \ J <br />