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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST ` ()Cj2(.M7 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> b��6 2�3 SRoO 0 � <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS [ .;'� K} Mr��QSt o 1 SDi j 1 <br /> so-eet Number Direction J Street Name CIt Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) A� li <br /> `7h J <br /> Street umber Street Name <br /> CITY STATE ZIP <br /> S�c3ck�t 6Y, STATE gS2.a L <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> (114 C0 Li�y0 <br /> PHONE#2 Em BOS DISTRICTLOCATION CODE <br /> I ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR �JCC�� <br /> GMC, CHECK If BILLING ADDRESS <br /> BUSINESS NAME �. <br /> PHONE# En. <br /> )Gv \C oJho. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY Sur�C 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 laws. <br /> APPLICANT'S SIGNATURE: WLI "a6 DATE: <br /> PROPERTY/BUSINESS OWNERO OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILL/NG PART P 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 availableAnd at the same time it is <br /> provided to me or my representative. ove <br /> /4Y <br /> TYPE OF SERVICE REQUESTED: CE <br /> COMMENTS: <br /> NovJQ XZ2 <br /> �C7)y�EP,gR�AL ry <br /> c,Inanye � r� <br /> ACCEPTED By: EMPLOYEE#: DATE: `I <br /> ASSIGNED TO: �, EMPLOYEE#: DATE: it 9 2-2- <br /> Date Service Completed (if already completed): SERVICE CODE: I P 1 : R o O's <br /> Fee Amount: Amount Paid + Payment Date 2 2 2 <br /> Payment Type Invoice# Check#f Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> wvgmq� S <br />