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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type g�ol1f Business or Property 1 FACILITY ID# SERVICE REQUEST# <br /> l J CSL rv`c� `STlJ(s� 5 -0 0 0 1 0 7l <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> FACILITY NAME \ J\C\AAA- <br /> � <br /> SITE ADDRESS 1 l0 I ,l C4. cl Sls z IO <br /> Street Number Direction treet Name Cit L, Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) G t l' e,55e-W,c,/ <br /> Street Number Street Name <br /> CITY / STATE CIP <br /> �Ut\oGIC- ,4 9 53 <br /> PHONE#1 C Q c EXT. APN# LAND USE APPLICATION# <br /> (Z(!�) SO?5 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ^ � � ��t� <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME /� �v l j - _ �l � \ �� 1 t. _._�5 PHONE# 5�5 I Gg� Exr. <br /> HOME or MAILING ADDRESS �J ^ JG�/Vv� FAX#�I <br /> 4aG 55e to�P� 5{'. `7�� A ( 21-�) <br /> CITY �l \ __ STATE (f'4 ZIP 953 SG <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,Standards, ST TE and F DERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER RATOR/MAN//gg�GF: OTHOP ER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PAR7'Y�prc f of a Itorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: en applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release o 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: C1 <br /> COMMENTS: �� <br /> Ely 10AQUt 9 <br /> ACCEPTED BY: `" �� �p EMPLOYEE#: DATE: <br /> ASSIGNED TO: > EMPLOYEE#: DATE: /S <br /> Date Service Completed (if already completed): SERVICE CODE: Sf Z P/E: <br /> Fee Amount: Amount Paid Payment Date D / <br /> I <br /> Payment Type I Invoice# Check# Received y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />