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SAN ,JOAQUIN C` N'1'y ENVIRONMENTAL HEAL'1T EPAR'I'MEN'I' <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID 9 SERVICE REQUEST y <br /> ���A�orj6, Co DOD &fZ 47 aoD_3�1y'53 <br /> OWNER It OPE RAT R <br /> /tea' CHECK II BILLING ADOa ESS <br /> ,�pp` v <br /> FACRmNAMSBG <br /> S# DDRESS / <br /> 1fjf <br /> StreetNumberDirecllon #4511 .Street Name 1 P Code <br /> HOME r MAILING ADDRESS (11 Dlffe enl from Slttee EDs D <br /> a� twx .� <br /> Street Number Street Name <br /> CITY I - STA LP '© <br /> N <br /> PHONE 11 EXT. APN N LAND USE APPLICATION/ <br /> 7-w s s' <br /> PHONE 12 Exr. BOS DISTRICT - LOCATION CODE <br /> ( I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR � CHECKII BILLING ADOaEsS® <br /> BUSINESS NAME /' PH NEA Exr' <br /> A /T /-+alll//GOA1 & AL -S M�4 p- !� QJ <br /> HOME Or MAILING A.DORE55 FAX A <br /> vG Cil �T�� �rC✓ I/'IC� ) S'.5�- 0 / <br /> CITY 2'`D J � STAT ZIP <br /> 1.5-12 <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that f have prepared (his application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> CDUNW Ordinance Codes,Standards,STA • and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: t Q <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MA AGER ❑ 0TnERAUTTIORIZED AGENT AI , 4111 W.04JA,16—� <br /> If APPUCAVT is Not the UIWNG PARTY,proof Ofauthorization to sign is required Tiue Ia yC <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 /> CSIT <br /> TYPE OF SERVICE REQUESTED: ��/� �QY,:� RECEIVED <br /> COMMENTS: un f e w ��, g '� o j SEP 1 2004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED SY: EMPLOYEE#:- /� DATE: a' <br /> ASSIGNEDTO: EMPLOYEE#: DATE: <br /> Date Service Completed (it already completed): SEImCECOOE: � 2 PIE: -23p . <br /> Fee Amount: ? Amount Paid a7 L O- Payment Date U <br /> Payment Type Invoice# Check# Received By: <br /> EMD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />