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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> TK0,\ <br /> f Business or Property FACILITY ID# <br /> SERVICE REQUEST# <br /> SR o0�2 g2 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> �L <br /> FACILITY NAME <br /> SITE ADDRESS z (1-� / IIp/ <br /> Street N tuber Dird'ctfon `v ff o �Streat Naam-e c1tv Zip Code <br /> HOME Or MAILING ADDRESSIf Different from Site Address) <br /> ) -L t r- 61AVlv0 }eiA <br /> Street Number arreet Name <br /> CITY STATE <br /> C/Vor- ZIP i= n 1 <br /> P�nH/O�lN�,Ep#,1 Ex . APN# LAND USE APPLICATION <br /> # �-C/ <br /> W V) <br /> PHONE#2 Ezr. BOS DISTRICT LOCATION CODE <br /> I ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> C 0 CHECK if BILLING ADDRESS <br /> YBUSINESS NAME PHONE# _ Err, <br /> HOME or MAILING AD SS FAX# <br /> Zl ✓1Y� c ) � 520 <br /> CITY e \ _ STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersign 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, ATE and FEDE w . / <br /> APPLICANT'S SIGNATURE: <br /> DATE: �-7 ! 7 U <br /> PROPERTY/BUSINESS OWNER 13 / OPERATOR/MANAGER IX- OTHER AUTHORIZED AGENT El <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 t0 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 REQUESTED: lVy� R FN <br /> COMMENTS: ttoD <br /> 5.4/y � <br /> JN�/gQU1NC <br /> OU <br /> kEALTH p pN NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: `1 �rZ <br /> ASSIGNED TO: 1„ EMPLOYEE#: DATE: <br /> Date Service Completed (if\already completed): SERVICE CODE: (0 <br /> Fee Amount: C Amount Paid i Payment Date r' J <br /> Payment Type Mqo Invoice# Check# Received By: <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />