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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID # SERVICE RST # <br /> Ow 177 <br /> OWNER / OPERATOR <br /> CHECK If BILLING ADDRESS ❑ <br /> R �'t. 4c r4 r ..� I F I D Sc (--fau L� D �S rL is <br /> FACILITY NAME <br /> N 6v%m� A %W/ F t�i G e/VN E,%Jr ra 2 % SC tij � L, <br /> SITE ADDRESS ! N (e u � �� � � \ J 7.r.) %A'xN � X153 <br /> Street Number Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 1� c� 7L Street Number Street Name <br /> CITY STATE ZIP <br /> At ' TEct4 C k 3 CO <br /> PHONE #1 ExT• APN # LAND USE APPLICATION # <br /> �S ZS . Z& (l <br /> PHONE #2 ExT• BOS DISTRICT LOCATION COP <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Mt✓ (L I� �--Ihlr' � r � ( n.7(^ �,IV� � 2->t11k1.(� SW It�"T> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE # ExT. <br /> i 'J C Z mac; 2 _Z Z- <br /> `I <br /> HOME or MAILING ADDRESS FAX # <br /> Z � uPc: AiT ccoo gvC ( 2 �A'1 ) Z5 `l <br /> CITY STATE <br /> IP <br /> rM .� T� c ,�� G G S3 <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, STATE and FEDERAL laws . <br /> APPLICANT' S SIGNATURE : / ( — DATE : ( 9 l <br /> PROPERTY / BUSINESS OWNER ❑ o OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT C l `1 I L- eri Cr11 .N f t <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 : (,1 � v 7 W A �t PLA ,) <br /> COMMENTS: ` D <br /> sAN J W 032020 <br /> HFA THOq MFtV�UNTY <br /> gRTM C <br /> ACCEPTED BY: EMPLOYEE # : DATE : <br /> ASSIGNED TO : [ EMPLOYEE # : DATE : <br /> Date Service Completed ( if already completed) : SERVICE CODE: ! PIE : /r- <br /> Fee Amount : — I Amount Paid 3 � �� Payment Date (p3 <br /> Payment Type Invoice # Check # ,3739 Received By : <br /> EHD 4&02-025 SR FORM (Golden Rod ) <br /> REVISED 11 /17/2003 <br />