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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# OA S S RV�ICCEE REQUEST# <br /> 9S/ EN f- " o <br /> OWNER/OPERATOR10/ <br /> CHECK If BILLING ADDRESS <br /> lC rVA-N'FW0r?-TH <br /> FACILITY NAME <br /> SITE ADDRESS � � J -1-05f�PH (LOAD /Y)ANVTF—cA 9'5336 <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P. o d Street Number Street Name <br /> CIN STATE ZIP <br /> W.4 rj EcR S <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> o- � - <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CO <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS O <br /> 0 �IESN� <br /> BUSINESS NAME PHONE# EXT. <br /> 5 GC L Al o <br /> HOME or MAILING ADDRESS FAX# <br /> K3-714 <br /> ( ) <br /> CITY i� C STATE ZIP 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 apnhication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ,TE and FkQAL.laws. <br /> APPLICANT'S SIGNATURE; DATE: lo-7 /7 /o2be2lJ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ �OTIIIERHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable. 1,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 ENVIRONMENTAi.HEALTIT 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: pl/✓TSE100AT? C <br /> COMMENTS: DEC 0 D 202 <br /> SAN JOAQUIN COW TY <br /> ENVIRONMENT <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: Z-- EMPLOYEE M DATE: �' (N aO d J <br /> ��Z <br /> ASSIGNED TO: M EMPLOYEE M DATE: /a G /,;, ?U <br /> Date Service Completed (if already completed): SERVICE CODE: P I E: q J 1 <br /> Fee Amount: -;E 3 Amount Paid 3 Payment Date 2 9 20 2 JP <br /> Payment Type LG� k Invoice# Check# 3 6 ' Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />