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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Spaml-/ 5 <br /> OWNER/OPERATOR rh <br /> CHECK If BILLING ADDRESS <br /> -�-6ra� Rye-IaS ez <br /> FACILITY NAME <br /> SITE ADDRESS . 7 <br /> ,Street Number Direction St et Name J Gitl I ZI C0 J <br /> HOME or <br /> MAILING ADDRES (If Different from Site Address) <br /> t e.lf' Street Number Street Name <br /> CITY STATE ZIP <br /> UJ ar Lt Ca s <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> (510 )-+5&-}0123 <br /> PHONE#2 Ex . BOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAMEiU, Cas �Q `�Ghtq PHONE# En. <br /> I <br /> HOME or MAILING ADDRES 11 FAX# <br /> T ( ) <br /> CITY l Gl- lA-)00 STATE C,A 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 Coder,Standards,STATE and FEDERAL laws. <br /> , tel! <br /> APPLICANT'S SIGNATURE: D 1 as DATE: ' D-3 — ZO-)-2— <br /> PROPERTY/ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR./MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT 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 same time it is <br /> provided to me or my representative. PAY <br /> TYPE OF SERVICE REQUESTED: NECIelven <br /> COMMENTS: AIG UV ? <br /> 3 20?? <br /> SAN NVIROJOAQUIN <br /> N CDEN UNTi, <br /> HEALTH DEPART NT <br /> ClnavlaC S{'1( <br /> ACCEPTED BY: J L CkV4�j/I EMPLOYEE -/IO DATE; 93 ZZ <br /> ASSIGNEDTO: VVV��y At !'EMPLOYEE ! DATE: ��l 2Z <br /> Date Service Compl ted (if already Completed): SERVICE CODE: P E: <br /> Fee Amount: Amount Pai 66 O,C Payment Date 23 ZZ <br /> Payment Type Invoice# Check# I�-�D7 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />