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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S-1 0 FLA lu+ rA�OD�2�t-I -Nz co$-�32 <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> U R M- 1 +RO'DH►Aw <br /> FACILITY NAME <br /> S t� F3w w i C _ <br /> SITE ADDRESS \�� W KF 1'rLCM19kJ LfJ <br /> Street Number I Direction ` Street Name Citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE V ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (�P — d52 <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS` <br /> SU�1 U � ��[Z' � <br /> BUSINESS NAME PHONE# EXT• <br /> S V l�tiv 0�i 51 {J IcH M 35 a - I q 18- <br /> HOME or MAILING ADDRESS FAX# <br /> �U'-A (Q -AiuD Pt13GLE SY { ) <br /> CITY ' ' IUC�zTV '`.l STATE �S2-60IP <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 /> ,�- `1 ` 2r <br /> APPLICANT'S SIGNATURE:j �y-T�"'JJ end ��k`� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR 1 MANAGER 1;x OTHER AUTHORIZED AGENT❑ <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 /> 4P r <br /> TYPE OF SERVICE REQUESTED: av�av1 �Eivr— <br /> COMMENTS: eb <br /> �anIFES <br /> 19 2071 <br /> H E►vv,a0NlnrC00V <br /> ACCEPTED BY: EMPLOYEE : DATE: y 2 <br /> ASSIGNED TO: SYZ EMPLOYEE#: DATE: 1 <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E:: ` R <br /> Fee Amount:i� �C�2 Amount Paid /'S-�2'06 Payment Date X1.712-l v <br /> Payment Type Invoice# Check# Received ByEHD : <br /> REVISED <br /> 111 5 SR FORM(Golden Rod) <br /> REVISED 91/17/2003 V <br />