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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Properly FACILITY ID# SERVICE REQUEST# <br /> SQpO �'���� <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS Li <br /> 160`/.r <br /> FACILITY N ME <br /> CF g OLL! <br /> SITE ADDRESS 134 1 W YOSEMITE AVE MANTECA 95336 <br /> Street Number I Direction Street Name city zip CQd. <br /> HOME or rM-�AILING ADDRESS (If Different from Site Address) / <br /> `� V14i] Street Number / 1 Street Name <br /> CITY STATE ZIP <br /> (- ' 33 <br /> PHONE#1 Ext. APN# LAND USE APPLICATION# <br /> ( til t - 6532- 2t°I- LA10- 'OCA <br /> PHONE#2 _ Err. SOS DISTRICI LOCATION CODE <br /> 0b "77 - )I{ }`1 JAS A16t11 L <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAMEe ^ PHONE# <br /> C s <br /> HOME or MAILING ADDRESS Will <br /> S— ( ) <br /> CITY STATE /I/L ZIP Zl <br /> h C <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 t�bg performed will be done in accordance with all SAN JoAQuiN <br /> COUNTY Ordinance Codes,Standards,S FEDERAL law / //•7 //.�,, <br /> APPLICANT'S SIGNATUppRIIE: �' ��_ DATE;_--Z =`��- <br /> PROPERTY/BUSINESS OWNER WI OPERATOR!MANAC>ER 13 OTEIEaADTHomzED AGENT 13 <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 jl a same time it is <br /> provided to me or my representative. A Y <br /> TYPE OF SERVICE REQUESTED: IAZCFJ <br /> COMMENTS: 9 <br /> tcb� lt <br /> /VJOc PCa✓�f OC <br /> yFA Ty�ECO- <br /> P4 t <br /> l <br /> ACCEPTED BY: EMPLOYEE#: DATE: - <br /> ASSIGNED TO: F?. V1 t/W EMPLOYEE#: DATE: ',-2-& <br /> I <br /> Date Service Completed (if already completed): SERVICECODE: Z3 P I E: <br /> Fee Amount: 5 Amount Paid �J(e d0 Payment Date <br /> Payment Type �� Invoice# Check# 'Z 8 Received By: <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />