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SAN JOAQ COUNTY ENVIRONMENTAL HEA/DEPARTMENT <br /> SERVICE REQUEST <br /> t Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> go 3�y8 c�338 <br /> OWNER/ OP TOR1 C.T, �tL CHECK If BILLING ADDRESSO <br /> I - IC 6�S 1 L� r/ <br /> FACILITY NAME �n -r���jn� NCp� �'I �fT(pN -y <br /> SITE ADDRESS 1-� GJp� /�C),) lfl-f!O 4auSe t�-,k/22AC <br /> 'Z4o �' Street Name Cil Zi Coda <br /> Street Number Direction <br /> HOME or MAILING ADDRESS (If Different from Site Address) O XT k �( �a-t� L(tN <br /> - W 1 �i L'"( N �' Street Number Street Nam375 e <br /> STAT ZIP <br /> CIT Y�� LW �� G12c�K CA ��� <br /> PHONE#1 EXT. APN# LAND USE APPLICATION It <br /> (-(z5) 6 74- G 707 <br /> PHONE#T <br /> E.T. BOS DISTRICT LOCATION CODE <br /> ( RzS) Ct74 - 4-o 83 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> PHONE# ear. <br /> BUSINESS NAME <br /> HOME of MAILING ADDRESS FAX# <br /> STATE ZIP <br /> CITY <br /> BII.IANG ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all Site and/or project specific ENVIRONMENTAL HEALTII 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 1 have prepared this application and EEE;�� <br /> rformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards',STAT:and FED �^APPLICANT'S SIGNATURE: DArE: J(21 (03 <br /> PROPERTY/BUSINESSOWNFR OPERATOR/MANAGER ❑ OTntzaAUTIIORlzEDAGENT Sri, ENVIL EK 7' <br /> if APPLICAN"f is nnf the BILLING PAR77,proof of tnAhuriZnfiat to Sign is required <br /> Title <br /> AUTHORakrION TO RELEASR 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 HGAL'rli 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 /> CONMENTS[ <br /> MAY 2 1 2003 <br /> ^ <br /> APPROVED 0Y: EMPLOYEEM i DATE:s b� <br /> _ <br /> ASSIGNED TO: EMPLOYEE#: 3 DATE: (/ <br /> SERVICE COOS: <br /> Date Service Completed (if already completed): !i <br /> Fee Amount: 53 Amount Paid Payment ate <br /> Payment Type <br /> Invoice# Check# D Received By: <br /> SERVICE REQUEST FORM <br /> EHD 48-01-025 <br /> REVISED 0-5-02 <br />