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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# 11 SERVICE REQUEST# <br /> SX 00 O` �� to XE <br /> OWNER/OPERATOR <br /> wCU '1 Vl/. CHECK If BILLINGADDRE55E] <br /> FACILITY NAME �/^ I !�� /p .� ,, <br /> SITE ADDRESS 7-l" l-) Str�l 1.. II ` AR'A S L'�W��' °Csw3 <br /> SVeet Number Direction Street Name cffi, Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 2,0 O <br /> Street Number I V� Street Name <br /> CITY STATE IP <br /> 712 r2 <br /> PHONE#1 1 1 Ex , APN# LAND USE APPLICATION <br /> ( I 1 <br /> PHONE 42 �'Z/ / Exr. BOS DISTRICT LOCATION CODE <br /> /✓JV✓)✓✓' CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR p� �0 <br /> (��, 1(/� CHECK If BILLING ADDRESS <br /> BUSINESS NAME ^ ' I /) k f/ O{D PHONE E, <br /> HOME Or MAILING ADDRESS �t ,^ A!1 �'^ r JF'r# <br /> CITY i ) ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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: F 0'r"z Ca7aViCL& DATE: <br /> PROPERTY/BUSINESS OwNERW OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> Jf APPL/CANT is not the BLLL/NG f ARTY 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 same time it is <br /> provided to me or my representative. P <br /> TYPE OF SERVICE REQUESTED: �J�Q y tl( Q `�S ��`� In,i• <br /> COMMENTS: �e <br /> ENV gQUI]y C 2 <br /> HfALry�E UI Tt <br /> n r <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNEDTO: ' / J:'7 EMPLOYEE#: DATE: {� <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: I G�2 Amount Paid `" I r '1, Payment Date P/o /7/rZZ <br /> Payment Type 1 Invoice# 1 IC-heC/ry 12/1/y�7�// p�/ u-{• �_ <br /> /I'''l I/k < Received By: <br /> EHD 48-02-025 U SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> p�2oS-I�-SSw S <br />