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SAN JO*N COUNTY ENVIRONMENTAL HEA*DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> fKcsldtr,t� al <br /> OPERATOR <br /> IM 1� f1/_ � „�„ UC t /t — CHECK If BILLING AODRE38® <br /> FACRNYNAME q M 1I�6 /� Jo�� � (�' i 1, l�ct,l.,� <br /> SITE ADDRESS 96,5o <br /> mcn-bra. I oq 1:!�= <br /> SlmelNumber Directioa 8ve^et Nemo I Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) TJ•�1 :�"" l� <br /> T Stmel Number �✓• avast Nama <br /> CITY' STATE ZIP s•�,r.�. / <br /> PRONEM ` EXT. APN# LAND USE APPLICATION# �fLJ�• <br /> AAY n114 Qc'i81 8 <br /> 2411 OzLi <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR 1' CHECKIf BILLING ADORFSS® <br /> BUSINESS NAME /T �y]J� Or _t �� PHONE# EXT. <br /> HOME or MAILING ADDRESS F x# <br /> (�`v� <br /> CITY , STATE ZIP 75Gbe—1 <br /> BILLING ACKNOWLEDG MENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all Site and/or project specific ENVIRONMENTAL HEAL9•H DuPARTMENT 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 app1. tion and that the work to beJ n I accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, T and FEDERAL laws. �( „0� �Q / / GL <br /> APPLICANT'S SIGNATURE: \vJ ��/ DAT�E:a {GAha�lh�Ij� ,J <br /> PROPERTY/BUSINESS OWNF.RIO OPERA'POR/MANAGER ❑ OTHERAUTHORIZEDAGENT7$ �P7,( �Yp¢�t[" <br /> /f APPLICANT u not the BILLING PARTY proof of authorisation 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 a5 Soon as it i5 available and at the same time it i5 <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: T-aj , <br /> COMMENTS: <br /> D _ <br /> ACCEPTED BY: MPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount: Amount Paid payment bate <br /> Payment Type Invoice# u Check# Received By: <br /> EHD 48412.025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />