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SAN JOAQUIN#LINTY ENVIRONMENTAL HEALTHI&PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> L-f AAL <br /> OWNER/OPERATOR <br /> �L CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS �1L.• ffT��l L'brw�O <br /> G !� Street Number Dlreetlon SlreeeA/l Name City ip Code <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 /> (ate) ;;P 7 6-44-2 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> M•) I- I Jr4' 1 CHECK If BILLING ADDRESS <br /> BUSINESS NAME r/K�"' v Q� PHONE# E'R' <br /> �✓ '/ EN h'/ S37 <br /> HOME or MAILING ADDRESS PioK 97 (l ) 9 84"—It, <br /> CITY �- STATE n _ ZIP 95763 763 <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 projector <br /> 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 FERE laws. �j <br /> APPLICANT'S SIGNATURE: /� � DATE: / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT CST �on._1rdAGP�' <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tule <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 enviromnental/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: 7 fJ ()� 46,t It VA GGrr�fey <br /> COMMENTS: U�—f ` 1 -� RECrEIVED <br /> LL FEB 112005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL 1 <br /> ACCEPTED BY: EMPLOYEE q DATE: HO <br /> ASSIGNEDTO: EMPLOYEE M Gfi DATE: <br /> Date Service Completed (if alrea completed): SERVICE CODE: PIE: <br /> Fee Amount: 4c Amount Paid 8y Payment Date <br /> v <br /> Payment Type Invoice# Check# R ceived By: Ii! v <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />