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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> t <br /> SERVICE REQUEST <br /> Type of Business or Property r- FACILITY ID# SERVICE REQUEST# <br /> u STRIA V0q-� <br /> CHECK if BILLING ADDRESS <br /> OWNNEER7 I OPEOPERATOR ,/ �} <br /> !' �c . eA R/- PA R 7r A VA R2/'"t <br /> / ❑ <br /> FACILfrY NAME <br /> dAg m E51-4 ',vp a.-5;-rR A L ?,A e-1 <br /> SITE ADDRESS d 3033 -f0a7- 1 A/ R47-*6 7-R-,4cy <br /> Street Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) �7S jrG l/1/�7-T IZ UD <br /> Street Number Street Name <br /> CITY7/ZA G STATE CA ZIP ��3a <br /> PHONE#1 Exi. APN# LAND USE APPLICATION# •¢ <br /> c ) '25�9 -/fin -/w sA - 9 -lo3 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> F CONTRACTOR 1 SERVICE REQUESTOR <br /> REQt1ESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT, <br /> S �d SuGT .tll 4, -4 03 <br /> HomF-or MAILING ADDRESS FAx# <br /> P- D. Box 3 794 <br /> CITY STATE KIA zip 17SSBl <br /> k <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this applic tion and tha the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST and EI~ laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ 1horization <br /> THER AUTHORIZED AGENT 1;,Y <br /> If APPLICANT is not the BILLING PARTY,proof of a 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: 961_Sr-r ST W4 7Z72 LV A -rry D <br /> COMMENTS: oma$ P�• NJE.i <br /> -'J ' t v� -�j RE(DEIVED <br /> bo �aaa <br /> ot s s l 3�'µ^ � SAN lOf�outri COUNTY <br /> �'V MENTAL <br /> ACCEPTED BY: EMPLOYEE#: DI}TjpLT PART <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Z 7� PIE: <br /> Fee Amount: L47 Amount Paid [ -D Payment Date :i'wo <br /> I Payment Type Invoice# Check# _�2 Received By: � <br /> EHD 48-02-425 ' SFi FORM(.Golden'F?ad)' <br /> REVISED 11/17/2003 <br />