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SAN JOAQUIN COUNTY ENIVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> [Type Business or Property (—� , t "--�M oO <br /> OWNER I OPERATOR J.111U, CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME SN6,LL -rJF l/_ JAL <br /> MOME <br /> R==E::]Yr Y.- V" ,A711 6SOGTd� gS„ZQ3 <br /> 36)5, rfU p�� Street a e Clt ZI Cod. <br /> AILING ADDRESS (if Different from Site Address) <br /> 5lreel Number Street Name <br /> STATE ZIP <br /> CITY <br /> PHONE#7 EXT' APN# LAND USE APPLICATION# <br /> EXr. BOS DISTRICT LOCATION CODE <br /> PHONE#2 <br /> ( ) <br /> CONTRACTORS/SERVICE REQUESTOR <br /> REQUESTORCHECK H BILLING ADDRESS <br /> �AA <br /> h'V 5/-4,4w PHONE# EXT, <br /> h7 <br /> BUSINESSNAME ^ 6Lp �^ q�^�Gx 9//p 503 -2 -3$ <br /> FAX tl,� S' - 551 S <br /> HOME Or MAILING ADDRESS,�2Z� n �ngRKtt/AY ( ) <br /> CITYaA 0_ t� STATE r-,4ZIP G�St/JO.� <br /> (, r? 3l-O SN <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 ENv1RONMENTAL HEALTH DEPAR'T'MENT 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 JDAQuIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> E: <br /> APPLICANT'S SIGNATURE: DATE: <br /> G�l7MOU9 ✓G� rlAd `' <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑' OTHER AUTHORIZED AGEML7T <br /> IfAPPLCANT is not the BILLING PARTY,proof of authorization to sign is required <br /> 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 JOAQUtN 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 /> RF MF <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: e.. <br /> 1 D"N <br /> I <br /> EMPLOYEE#: DATE' f k <br /> ACCEPTED BY: <br /> ASSIGNED TO: aJLr Ta EMPLOYEE#: DDA ' I <br /> PIE; <br /> RVI <br /> Date Service Completed (if already completed): $ECE CODE: v 6 <br /> Fee Amount: <br /> Amount Pa � L5-95-,O Payment Date <br /> �� <br /> Payment Type /�jQ� Invoice# <br /> Ch # 06 - Received By: <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 - <br /> REVISED 17/17/2003 <br />