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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST P R D Il a5lq <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 6 91 <br /> OWNER/ PERATOR I'� ^� - <br /> —7_ ❑ <br /> YA I CHECK if BILLING ADDRESS <br /> FACILITY NAME O —�^ n 1 L L <br /> SITE AD RESS rrt `Itl %n/ / /�/j f`� 7 <br /> (.Street Number Direction v t L�Str t [ 'Ca •ZI 19.—Un <br /> le U/ / <br /> HOME I G D S ( iffe a fro to Address) / , //y(t <br /> 6/ C.[�Llslt}/t!t'tJNumber eel ame/[/ <br /> CITY STATE zip <br /> PHO E#1 /„ , /�� Ex. qpN# LAND USE APPLICATION# <br /> ( /r/J D I <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> l`�, n, <br /> (� t//w1 7Z— CHECK If BILLING ADDRESS <br /> �/ <br /> BUSINESS NAMEbbo I� ID '/1 <br /> PHONE <br /> HOME orMAILING ADDRESS %� �� / FAX# U U <br /> U (/ ) <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 TE and FEDERAL ws. /t� 7 j <br /> APPLICANT'S SIGNATURE: DATE: / lo� 27 Iy"2,1 <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPL7CANT is not the B/LL/NG 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 the or my representative. P <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> APR 1 7 1011 <br /> JOAQUIN <br /> If 771 0�NWRQNE.NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: �I <br /> MJU <br /> ASSIGNED TO: 1 EMPLOYEE DATE: 7// /LI <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> 61 P1 11 APO�2- <br /> Fee An-I Amount Paid Payment Date <br /> iJ r <br /> Payment Type Invoice# Qtle r7 l I_ �, �"} <br /> LST 1 Received Bye <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />