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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> --FType of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1 <br /> rr �4 RQ�B�-415 <br /> OWNER/ PERATOR t` ��"xe1�, <br /> ') �) �`�C / Tc 'V' CHECK If BILLING ADDRESS <br /> FACIL Y N I 2 1/ VVV"' <br /> t <br /> SITE A DRESS <br /> 2� Street Number ( ctlon �r gtrect Nan e CI <br /> HOME Or MAILING ADDRESS (If Different from Site Address) -T <br /> I.e `!J <br /> O Slreel NumberF 4FaA t <br /> CITY 5 STATE` ZIP ` <br /> PHONE#'I Exr. APN# f LAND USE APPLICATION# A9 <br /> tq� ) 3 6 °a iq� ItEJ_ .M\ C t <br /> '7,4 <br /> PHO E EXT, BOS DISTRICT Locil f— D <br /> CONTRACTOR/ SERVICE REQUESTOR SAN'Jo <br /> gQ <br /> REQUESTOR ` //.�� <br /> �� D12 Q� CHECK if BIL Il P NM Nry <br /> filea <br /> BUSINESS NAMEPHONE,# EXT NT <br /> (� C <br /> HOME Or MAILING ADD SS FAX# <br /> CITY ` ( STATE C 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE; <br /> DATE: �IZZIM2- <br /> PROPERTY <br /> /BUSINESS OWN Ell �OPERA-1 MANACER ❑ OTHER AUTHORIZED ACENT <br /> !f ❑ <br /> �PPt.I('.IAT is not the B1ti,lNc P.dIt7�Y proof of authorization to sign is required True <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 JOAQIIIN C0H1N'I'Y ENVIRONINIENI'AI.1-IL-'A1.1'H DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> n <br /> TYPE OF SERVICE REQUESTED: 44 t I ► / <br /> NY Ad' <br /> S I tall <br /> COMMENTS: IV <br /> ( lj�N� -C� i�. �� G( ��! <br /> 12trkjet <br /> ACCEPTED BY: �M EMPLOYEE#: DATE: G a 7yy�j <br /> ASSIGNED TO: EMPLOYEE#:AIA- DATE: l i2 `GZvbL1� <br /> Date Service Completed (if already completed: SERVICE CODE: <br /> Fee Amount: C) 'q Amount Paid bg' Payment Date /2-S� 2 n 21 <br /> Payment Type Invoice# Check# 72 <br /> s� Received By: <br /> EHD 48-02-025 Golden Rod RM <br /> REVISED 11/17/2003 ( ) <br />