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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business <br /> rp11 or Property FACILITY ID# SERVICE REQUEST# <br /> QDAtYl <br /> Si 0eY� �Q 17 <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS 1'7,,5 1 YY\V to .,' La-,)P- <br /> Street <br /> a.,,eStreet Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (boy ) 3S) - Lo JIg JCII� D!grl <br /> PHONE#2 EXT. BOS DISTRICT �� LOCATION CODE <br /> (20 ) 3W- -7lo <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> - (! <br /> HOME or MAILING ADDRESS FAx# <br /> CITY STATE ZIP cl 5 z- v <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,S TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 4n;!=4 DATE: �IL7 IzI <br /> PROPERTY/BUSINESS OWNER551" <br /> �PERATOR/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.// \\ <br /> TYPE OF SERVICE REQLIESTED:—„bo; 7lJ\1"0. t 1 l Q <br /> COMMENTS: <br /> � a <br /> 4702 <br /> �94 <br /> TyOFpgRN H <br /> ACCEPTED BY: Li EMPLOYEE#: DATE: T <br /> ASSIGNED TO: t) EMPLOYEE#: DATE: J� a <br /> Date Service Completed (if already completed): SERVICE CODE: 5 CPIE: 1 <br /> *1111 OR <br /> Fee Amount: Amount Paid ;. - Payment Date / <br /> Payment Type' A2 Invoice# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />