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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Fmb25zq Si�uS31l °I <br /> OWNER/OPERATOR �'I <br /> CHECK If BILLING ADDRESSE] <br /> 1 <br /> FACILITY NAME U � f <br /> / /` Q <br /> SITEADDRESS �Fjz6 l0U)u' Sao Gr,,v-n S-f-bCl� }-0✓I �S Z l � <br /> Street Number Direction Street Name _ U city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site `Ad'dress) <br /> \ V a Street Number Street Name <br /> CIN STATEZIP S JL <br /> Y rfoT <br /> PHONE#1 E77r# LANO USE APPLICATION# <br /> ISO) 0 - X80 L( <br /> PHONE#2 Exr• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> G• � V � Q CHECK If BILLING ADDRE55O <br /> BUSINESS NAME —C�— --f' PHONE# EXT, <br /> ` O i 1 riG1 ID <br /> T —q <br /> HOME or MAILING ADDRESS FAX# <br /> 2 S c S ( ) <br /> CITY STATE ZIP O <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: S aUc' Cluj Sv DATE: C-'T I 2—I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANTisnottlto BJLLJNGPARTY 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 enviromnentaal�l/ssi�itt�c/■aas��seessss �eent <br /> information to the SAN JOAQUINCOUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at�I9�1Tl EN IS <br /> provided to me or my representative. RECEIVED <br /> TYPE OF SERVICE REQUESTED: 14n Wl� <br /> COMMENTS: MAY 11 <br /> SAN JOAQUIN COUN <br /> ENVIRONMENTAL <br /> HEALTH DEPARTME T <br /> ACCEPTED BY: q C EMPLOYEE#: r' I DATE: <br /> ASSIGNED TO: ( J EMPLOYEE#: ��7[LI DATE:tJ' n <br /> Date Service Completed (if already completed): SERVICES CODE I El: 1W2 <br /> Fee Amount: 15 151100Amount Paid S Z Payment Date •moo e,>-. <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />