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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST F P, Q 5:2 '� ( y <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> L- <br /> f �` CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME 1 ) <br /> SITE ADDOSS 7~ <br /> r; CION <br /> um a plrectian Street Name zip Code <br /> HOME or M(AILING ADDRESS (If Different from Site Address) <br /> F r 3 ALAW Street Number ${pQe'!Mama h L)r' <br /> CITY f 1 I arae vt SC rT ZI <br /> PHONE#1 I Ex7. APN# LAND USE APPLICATION#E <br /> (M2-6574LOO <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> { ) <br /> CONTRACTOR�JTRACT ]�R� l SERVICE REQUESTOR <br /> RELIUESTOR + v-C(�_� C/ � + " ❑ <br /> 11 � CHECK If BILLING ADDRESS <br /> BUSINESS NAME PH EXT, <br /> kI - M�1c�1 ) 3 ,2, 'W, 6r-, <br /> HOME or MAILING ADDRESS FAX# <br /> 3 I C11 <br /> CITY /}/llr yl 1cc STATE011 ZIP <br /> BILLING ACKNOWLEDGEMENT: f, 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,Slandards, STATE d ER-AL laws, --APPLICANT'S SIGNATURE: DATE: 5 31,2 f <br /> PROPERTY/BUSINESS OWNER❑ 04LOR/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 salve time it is <br /> provided to the or my representative. <br /> TYPE OF SERVICE REQUESTED:. <br /> COMMENTS; <br /> HE&'ORONMN OON7Y <br /> ^ Wi4i AR r <br /> ACCEPTED BY: YV\ EMPLOYEE M DATEC- /3 <br /> ASSIGNED TO: AM EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: O PIE: 1002 <br /> Fee Amount: �� Amount Paid f�� Payment Date <br /> I <br /> Payment Type Invoice# Check# Received By: <br /> EHQ 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />