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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> I C_.Q, Cha vi V4A-14 596(W11 <br /> OWNER/OPERATOR r <br /> L,,( ///}��� C- T,� /�R �- / �q CHECK If BILLING ADDRESS <br /> FACILIN NAME '\� _ lCe <br /> SITE ADDRESS /1 t3 j� L` �.� TUAI <br /> Stre¢t Num Direction Tact Name CI ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) fo <br /> treat mbar �'/ V t/Street Name <br /> CITY DC-KS <br /> �•-�� STATE Zip M )2-G )L7- <br /> PHONE#1 /Av) Ex[. APN# LAND USE APPLICATION# <br /> PHONE 2 S EM• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <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 FEDE laws. ,�,�) /S <br /> APPLICANT'S SIGNATURE: If,641 — DATE: <br /> "--PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> Ir APPLICANT i5 not the BILLING PART➢ proof Of authorization t0 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 REQUESTED: <br /> COMMENTS: Mop <br /> 7vkp <br /> ��Dq U/& 1021 <br /> 69Cry�F coo, <br /> ACCEPTED BY: �� EMPLOYEE#: �/] DATE: O' y <br /> ASSIGNED TO: l0l/� EMPLOYEE#: qg�v DATE: (( D121 <br /> Date Service Completed (if already Completed): SERVICE CODE: P/E: 3 <br /> Fee Amount: 2 W Amount Paid a i- Payment Date <br /> Payment TypeC, Invoice# A #Fr 3,1f 6(QC)4 13 Received By: <br /> EHD 48-02-025 /��.�vt \3`\ SR FORM(Golden Rod) <br /> REVISED 11/17/2003 Y` J <br />