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SAN JOAQUI' "OUNTY ENVIRONMENTAL HEALT"DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESSL <br /> C have I on- M-ea m Die <br /> FACILITY NAME ^t <br /> �'�YI U'T` S Z' C e C.reckrn <br /> SITE ADDRESS \AJ e_S} I I -t�\ C++f,� , —�'r �C♦ C y X 374 <br /> 1 2 7 4 Street Number Dir.&ian J Street Name 1 city Zip Code <br /> HOME of MAILING ADDRESS (If Different from Site Address) <br /> 2-y o Z 4LDe— Strcet Number Street Name <br /> STATE ZIP <br /> CIT)-0 9 Sao9 <br /> df-k' � <br /> PHONE#f �' APN# LAND USE APPLICATION# <br /> CO.,) x}74 - ZZ 91 ` <br /> PHONE#ZT BOS DISTRICT LOCATION CODE <br /> 01 b - GSIg <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Em <br /> HOME Or MAILING ADDRESS FAA# <br /> CRY STATE ZIP <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 or <br /> activity will be billed to me or my business as identified on this form It <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: 07 <br /> PROPERTY/BUSINESS OWNER❑ OPERATO /MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IjAPPLICANT is not the BILLING PARTY proof of authorization to sign is required 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 JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sante time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: 00,�,!:(.c.L--T'70,-7-7 C/J — �-r�✓ �v _ <br /> COMMENTS: PAYMENT <br /> RECEIVED <br /> JUN 2 7 2005 <br /> SAN JOAQUIN COUNTY <br /> ACCEPTEDBY: rj C.,IUE(IL-•� <br /> EMPLOYEE C, 3-y/ HEALT fiT Z7 �S <br /> ASSIGNED TO: VC,4 EMPLOYEE#: ((o�t 9 DATE: G .?- G S <br /> Date Service Completed (if already completed): SERVICE CODE: , 9 / PIE: <br /> Fee Amount:- C?3-O�) Amount Paid Payment Date <br /> Payment Type Invoice If Check# Received By: : <br /> EHD 46-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />