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SAN JOAQU�J OUNTY ENVIRONMENTAL HEALTI�PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACIL YIJ�$ 7/S SERVICE REQUEST# <br /> C A—S cS � ! vY� (✓f� �r<06� 2 1 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME \ J V'cv M <br /> SITE ADDRESS <br /> GtC L � --r/-CA C Q -73�/ Street Number Dlrection treeme � I / <br /> Zip Code <br /> C7 <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 /> (209) '6310 ^ Li 2.Z <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> t ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> l-2-2 CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> 1 (aoT) 36,r- <br /> CITY STATE 0/1 ZIP,? <br /> �(l <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 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: DATE: 3 —�yd <br /> PROPERTY/BUSINESS OWNERD OPERATOR/MANAGER D OTHER AUTHORIZED AGENTY <br /> IfAPPLICANT 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 ay3i1a47 EVAhe same time it is <br /> provided to me or;ny represcetati�:e. v:Ipn reM ` YYN EKED <br /> TYPE OF SERVICE REQUESTED: UST P- I 'w F-kS <br /> COMMENTS: MXR <br /> SA ENVIRONMET <br /> HEA[-TH pEPAR <br /> ACCEPTEDBY: I I/ N� EMPLOYEE#: D'?Sz DATE: <br /> l <br /> ASSIGNED TO: vV 4 EMPLOYEE#: 6,75/3 DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: Gig P l E: 2 <br /> Fee Amount: `--79 1 Amount Paid 2"7 e9 Payment Date <br /> Payment Type R-C Invoice# Check# 160 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />