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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> JFA S-�DU 640 7 <br /> OWNERS OPERATOR � I,O` <br /> tt•1h 11. CHECK If BILLING A00RES5� <br /> FACILITY NAME N s , ( Pzu - OF <br /> o <br /> SITEADDRESS rLp} p� 'T] ��.f /t\lam <br /> Street Number Direction Y " V ��$ ae't Name Av o "-Cit ZI Cotl� <br /> HOME Or MAILING ADDRESS (If Different from Address) <br /> tob V wt Street Number Street Name <br /> CITYvo`a STAT ZIP <br /> PHpN`#1 19 ( (01cb ExT• APN# LAND USE APPLICATION# <br /> PHYIOI.NEE##2 BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQITF4T0R <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME R 11 PH NEE E-T. <br /> HOME or MAILING ADDRESS FAX# <br /> U t2 ( ) <br /> CITY + STATE 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 I <br /> APPLICANT'S SIGNATURE: —_ DATE: <br /> OPERTY/BUSINESS OWNERD OPERATOR/MANAGER D OTHER AUTHORIZED AGENT❑ <br /> IrAPPLICANT 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 Sal Vea It is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ,� "! <br /> COMMENTS: <br /> 0 <br /> ��15�tlt�i 0� " oF MFNo�A . <br /> q,t r. <br /> ;- <br /> ACCEPTED BY: EMPLOYEE#: 30 DATE:T y - <br /> ASSIGNED TO: 1 EMPLOYEE#: V DATE: U114/2-1 <br /> t y I <br /> Date Service Completed (if already completed): $ERVICECOOE: P I E: <br /> Fee Amount: 15 Amount Pai /S� /,� Payment Date Q <br /> Payment Type Invoice# Chec/kk# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> � "o5D1�22°I <br />