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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST,# <br /> 7 (oo _ <br /> OWNER/OPERATOR CHECK if BILLING Anna ESS❑ <br /> FACILITY NAME <br /> SITE ASD-DfRE�S'S � l Z yJ/J�LB <br /> yY�� Street Number Direction r ( Street Name Ci Zi <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 /> ( 1 <br /> 0t(0 <br /> PHONE#2 EXT- BOS DISTRICT LOCATION CODE <br /> ( ) Z <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> f CHECK If BILLING ADDRESS <br /> P <br /> BUSINESS NAME PHONE# E-- <br /> --�1 (' e® �' .3.3`-1 <br /> HOMEory[IN DR FAX III <br /> '/ ( 1334/-10/ <br /> CITY STATES ZIP <br /> BILLING ACKNOWLED MENT: 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 o: <br /> activity will be billed to we 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 JOAQLM <br /> COUNTY Ordinance Codes,Standards,ST EDERAL laws. y� / <br /> APPLICANT'S SIGNATU)2tDATE: k-3&` ( 19 <br /> PROPERTY/BUSINESS OwNE OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICA is not the BILLINGPAnproof of authorization to sign is required rifle <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at thI <br /> above site address, hereby authorize the release of any and all results, geotecbuical data and/or environmental/site assessmen <br /> information to the SAN JOAQUON COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it i; <br /> provided to me or my representative. Poop r fzl'ft n A eyod� />L.A¢ Cf-{cc( <br /> TYPE OF SERVICE REQUESTED: V A-0 107._O <br /> COMMENTS: PAYMMI <br /> RECEIVED <br /> zo10 <br /> D� N01 <br /> SAN NCOU <br /> N <br /> TY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: ]) DATE: (� 30 I t] <br /> ASSIGNED TO: EMPLOYEE#: -fb� t 1 DATE: (2/3,0 t O <br /> Date Service Completed (if already completed): SERVICE CODE: 5a PIE: 360 <br /> Fee Amount: O � Amount Paid R 3 Q Payment Date 1 (o <br /> Payment Type Invoice# Check# S Z� ?� Received By-. <br /> EHD 46-02-025 SR FORM(Golden Rod <br /> REVISED 11/17/2003 <br />