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SAN JOAQUI- BOUNTY ENVIRONMENTAL HEALTH 'ARTMENT <br /> ... SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -T-qtk;a 3s l/ F ,', m5V3/6 <br /> OWNER I OPERATO /!A'l 0 <br /> CHECK If eauND AoaeEss 13 <br /> FACILITY NAME <br /> SITE ADDRESS <br /> ab..t mmhar c <br /> HOME or MAILING ADDRESS (k Different from Ske Address) <br /> Stmt Number beet m <br /> CITY STATE LP <br /> PHONE 91 Err. APN#/ LAND USE APPLICATION III <br /> �l <br /> (206 ? — 2S-76 <br /> PHONE#2 Em SOS DISTRICT LOCATION ODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILDNG ADDRESS <br /> BGSINEas NAME 9-575 Gn LLL � 746 <br /> HOME or MAILING ADDRESS �/ �' �L! FAX )9-'11 G7 <br /> CITY S' 7 (X-k�(� S <br /> STATE ZIP `1/l0 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 plication and that work t e performed will be done in accordance with all SAN JOAQUTN <br /> COUNTY Ordinance Codes,Stan ds, TE and FE L �••� <br /> APPLICANT'S SIGNATURE. r DATE: <br /> PROPERTY/BUSINESS OWNER21V OPERATOR/MANAGE OTHER AUTHORIZED AGENT❑ <br /> I.fAPPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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: <br /> COMMENis: <br /> ,1AY 2 1 zoos <br /> SAtFW RONIMENTA- <br /> HFJu-TH DEPARTMENT <br /> ACCEPTED BY: (J L ( v F.T . EMPLOYEE#: j 2..( DATE: ,s Z[ O G <br /> ASSIGNED TO: U 0„) ,vZ EMPLOYEE#: 3 I DATE: ,S Z[ G' <br /> Date Service Completed (N already completed): SERMCE CODE: I Pi E: G Si <br /> Fee Amount: Amount Paid 2Q (� Payment Date S�{ D <br /> Payment Type Invoice# Check# Re"bled By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />