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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property n FACILITY ID# SERVICE REQUESTT# <br /> i c� c, -�„r� s� `I U � I <br /> OWNER/OPERATOR (� { <br /> K H V-I ST a" "i 1 CHECK If BILLING ADDRESS E] <br /> FACILITY NAME <br /> LL�.$ C2.FA wl <br /> SITE ADDRESS <br /> 2 2(7 �tl r <br /> Street Number Dlrecll6 Vo"I Street Name CI Zi <br /> Code <br /> HOME or MAILING ADDRESS <br /> (if Different from Site Address) {'�11 <br /> T S ✓ "IF I_0 Street Number C" Street Name <br /> CITY STATE ZIP <br /> C 25 3 <br /> PHONE#1 Err APN# LAND USE APPLICATION If - <br /> (41n) 3q g gC14 v <br /> PHONE#2 E*T• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAx# <br /> CITY STATE ZIP <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 ;DERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: JuLj Z001 <br /> PROPERTY/BUSINESS OWNER❑ AERATOR/MANAGER ❑ 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. ,I <br /> TYPE OF SERVICE REQUESTED: Vj y <br /> COMMENTS: <br /> d' Oi wlSh l ps tit'/�� 1 ?Q21 <br /> N ENV,AQUI/V <br /> E9LTj1 flEp FNT�n <br /> ACCEPTED BY: C f f K CS'L� EMPLOYEE#: DATE: <br /> ASSIGNED TO: k-, 'vA a v--e- S EMPLOYEE#: DATE: 7-2-t —2 <br /> Date Service Completed (if already completed): SERVICE COOE:0�j/ P/E: /&02 <br /> Fee Amount: I 2- Amount Paid Payment Date 2 <br /> Payment Type CaO Invoice# �. I)C) I Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />