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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �-SiAuRn,.rr A Qpp230A Sa 008Q(o 145 <br /> OWNER/OPERATOR <br /> �,1�/�I�� ✓ CN CK If BILLING ADDRESSk <br /> FACILITY NAME <br /> SITE ADDRESS 3`�3 CJ V t�A�i Fic �v� s%crc..To�� 95-70-7 <br /> Veel Number Direction ams C <br /> HOME T MAILING ADDRESS (If Different from Site Address) ,q D /! 6V u A <br /> J <br /> ( / SVG 1 Number v/� C.� <br /> CITY J STATE_ ,SEZIP <br /> PHONE 11 U, _ EM APN# LAND USE APPLICATION# / <br /> (70) 1 10- 2 0- 330 <br /> PHONED Eu. BOS DISTRICT LOCATION COOF <br /> I ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Q,�,v n�"�. L� ��r�tL CHECK if ss❑ <br /> BUSINESS NAME PHONE# j�'I a� <br /> HOME or MAIuNG ADDRESS FAX# ff <br /> ( f) " 2021 <br /> CITY STATE ZMN C <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or autho Iiv same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with IS wtbjeC[ <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 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,ST and FE RAL laws. <br /> APPLICANT'S SIGNATURE: DATE: Z <br /> PROPERTY I BUSINEss OWNER OPE ATORI MANAG ❑ OTHER AUTHORIZED AGENT 13 <br /> Jf APPLICAhT 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 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: 1VW✓&-YL C.N"�Y� •-� �- ,r,.,,,,� <br /> COMMENTS: ?'N�i,{.7[L-T Th2_ Y�O^uµW✓"Y � �y nD1'Y-w•-/� � <br /> n�alte.YSUre- <br /> -fG.i <br /> ACCEPTED BY: /'L�. ` 1EMPLOYEE#: DATE: 2- S .2- <br /> AsSIGNEDTO: <ct cf O EMPLOYEE* DATE: tL _ -_z <br /> Date Service Completed (N already completed): SERVICE CODE: 04�, If PIE: <br /> Fee Amount: I Gj Z. 0 U Amount Paid 15-2-. d Payment Date <br /> Payment Type Lt(1 eQinvoice# Cheek# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />