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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST p/2 0/6 6 0 &1 <br /> Type of Business or Property FACILITY� IF-T-WNd1- <br /> ID## SERVICE REQUEST# <br /> X�0'TL TV <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> /� <br /> SITE ADDRESS/ _ 1 1 nl M!S .- <br /> l(f Street Number Dlredlon lel StreeWt N`a�e�V JTf KCI 21 Code <br /> HOME or MAILING ADDRESS (if 1Different from Site Address) <br /> Street Number Street Name <br /> CITY Si-o 1 S7AC TE., ZIP <br /> PHONE#1 h En. APN# LAND USE APPLICATION# <br /> (2011 I S°� Z <br /> PHONE#2 Es. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEST R . 1 <br /> `Ayt- w v-� CHECK If BILLING ADDRESS <br /> r <br /> BUSINESS NAME C"fl� IO I PINE# IIJJ 7 EXT. <br /> �v- �ln �0`1 S�aJ� S_I Z <br /> HOME or MAILING ADDRESS FAX# <br /> o. S3 ��H S1�rl�lvn CA <br /> CITY �L.C��^ STATE ZIP �S Z <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,Standard T x, 48 FE laws. <br /> APPLICANT'S SIGNATURE: � DATE: Z Z <br /> PROPERTY/BUSINESS OWNER OPERATOR;OPERATOR/ AGER ❑ OTHER AUTHORIZED AGENT[3 <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 theme time it is <br /> provided to me or my representative. q Y <br /> TYPE OF SERVICE REQUESTED: / �u,l CF <br /> COMMENTS: UG 1 <br /> oFPgNNou'O�ry <br /> R <br /> T'RE`NT <br /> ACCEPTED BY: /t EMPLOYEE#: DATE: D Z`� 2 I <br /> ASSIGNED TO: ' It ( 11 EMPLOYEE#: 3 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: ( � Z <br /> Fee Amount: 4 v" 2 _ Amount Pal15�2Od Payment Date H <br /> Payment TypeaeXt I Invoice# Check# <br /> By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />