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SAN JOAQU' AUNTY ENVIRONMENTAL HEALTH IPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# RVICE REQUEST# <br /> 64 -50 LVA) 6COL�(CO3L- <br /> OWNER <br /> /OPERATOR <br /> CHECK if BILLING ADDRESS <br /> AJ tN7 Q OlL(s srs - 'ao <br /> FACILITY NAME 1,7 re, .CA� <br /> SITE ADDRESS / J2 <br /> 1 T 3 9 Street Number l.(J Direcdon C 7` W Q✓ ��.' 96o�CXi:✓/ <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Senef Numbx asset Nems <br /> CIT/ STATE ZIP <br /> PHONE#1 APN S LAND USE APPLICATION 0 <br /> ' G3-3,70- a3 <br /> PHONE$2 BIDS DISTRICT LOCATON CODE <br /> (409 410- 400 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS O <br /> BusINESS)DIArJIp C L,�uG1r ff /I�,�/E✓��lt� /�f.r P?/-# 90"4-/S3-7 Ems. <br /> HOME or MAILINGDORES X <br /> O C9 J1- FA( �/rte 9PF-//i7 <br /> CITY V` /STATE ZIP l'J/ <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 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: &.0 DATE: N°— 10 �A <br /> PHOPER'1"N'/BUSINESS OwNERI� "I OR/MANAGER ❑ Of HER AU"rHORIZEo AGENT❑ <br /> lfAPPLIcANT is not the BgmNGPAKTY Proofofauthorizadon 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: v-,- <br /> COMMENTS: �? ®.� B�c�zr RECEIVED <br /> AUG 3 0 2000 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> r <br /> ACCEPTED BY: EMPLOYEE#: <br /> ASSIGNED TO: - (^✓�'� ,�) EMPLOYEE 8: / DATE: <br /> Date Service Comp if already co 11—a): SERVICE CODE: /a P/E: Z D <br /> Fee Amount: Q�'' Amount Paid S Payment Date D <br /> Payment Type tt,,- Invoice# Check t y Received By: <br /> EHD SE 11/1 SR FORM(Golden Rod) <br /> REVISED 17/17/2003 1 <br />