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SAN JOAQId— . COUNTY ENVIRONMENTAL HEALTI. DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ]FSMERVICE REQUEST# <br /> 0 3co `77 '7 <br /> OWNER/ OPERATOR CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME <br /> Si to LvM4Et <br /> SITE ADDRESS <br /> 17t 'V /4ALt1t1b--J AI%1 STocci Slo � <br /> Direction Streel Name City <br /> Street Number ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN # LAND USE APPLICATION# <br /> (ZbS) 777 47 - ► o - ► L <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 1 <br /> ,r V£ // CHECK If BILLING ADDRESS® <br /> BUSINESS NAME ! �. ROvA 4Z II PHONE# ExT. <br /> isto Jr Mfw'k Zs)f1 7^ 0 <br /> HOME or MAILING ADDRESS FAX# <br /> 137 S prw 90 .0-/) ( 2.tiS> 4`107 -11 9 <br /> CITY 3 TMIC r%,J STATE ZIP 9 S •Z <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: —16y� Ljj DATE: 7y�ZO • 2 P 1 <br /> p <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ,1aL /(y tL'F MA.4^0lt <br /> I,ffAPPLICANT is not the BILLING PARTY proof ofauthorization 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. ^ <br /> TYPE OF SERVICE REQUESTED: d /,.✓ Y�J <br /> COMMENTS: <br /> ACCEPTED BY: ✓ EMPLOYEE M DATE: <br /> ASSIGNED TO: �_ EMPLOYEE O / DATE: V7 Y-7 <br /> Date Service Completed (if already completed): SERVICE CODE: Z PIE: / <br /> Fee Amount: / Amount Paid / -► Payment Date <br /> Payment Type Invoice# Check# ZZS Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11117/2003 <br />