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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTH%PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -3k 71 5kcoS (' 53 <br /> OWNER I OPERATOR <br /> r,,� �1 CHECK If BILLING ADORES <br /> a� ZS <br /> FACILITY NAME r, „1' `nD) 'I y <br /> SITEADDRESS ^ ^ G1-5004Z60 <br /> reetN m er Dl rection / tree Name Ci Zip Cade <br /> Homg or MAILING ADDRESS (If Different from Site Address) <br /> 74Lt?E7 Street Number Street Name <br /> CITY '/ SJ1�E ZIP <br /> PHONE 1 Mr` Exr. APN# LAND SE APPLICATION# <br /> PHONE#2 En. BOS DISTRICT � LOCATION CODE <br /> T� )��l-a5 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> R QUEST,OR <br /> CHECK If GADDRESS® <br /> BU IN S NIM / A 6 6 L <br /> H E or MAILING ADDRESS FAX#� <br /> , 1 (914 ) 76D=IPV <br /> CITY 'GLV- C.1 STATE ZIP 11 <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 forth. <br /> I also certify that I have prepared this application and t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE nd FEL laws. <br /> APPLICANT'S SIGNATURE: 14 DATE: <br /> PROPERTY/BUSINESS OWNER❑ OP TOR/MANAGER ❑ OTHER AUTHORIZED AGENXA 1 <br /> IfAPPL/CANT is not the BILLING PARS 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. <br /> TYPE OF SERVICE REQUESTED: S ENT <br /> COMMENTS: FEB 17 <br /> 2W9 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENT <br /> HEALTH D ARTME <br /> PNT <br /> ACCEPTED BY: O C t.I C EMPLOYEE#: 3.Z DATE: -q-ft-7 O <br /> ASSIGNED TO: `,/O t f F-(—t t � EMPLOYEE M ?31-7 DATE: f—j 0 <br /> Date Service Completed (If already Completed): SERVICE CODE: S, P I E: <br /> Fee Amount: Amount PaidJl `S PaymerA Date 2- <br /> Payment <br /> Payment Type Invoice# Check# 2_ Received BW <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />