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SAN JOAQU41WCOUNTY ENVIRONMENTAL HEALTIN124;PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 7e7 S r�o©5g4 <br /> OWNER/OPERATOR <br /> 1/- L/t f- \ V✓ CHECK IT BILLING ADDRESS <br /> FACILITY NAME I` <br /> I <br /> SITEA6DRESS, `l /io e /'C� /5Cmla <br /> �ADDiiIIJJ uvtl1 Number Direction Street Name C Zi Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> S-r Street Number Street Name <br /> CITY <br /> S lzC 0 $ -TE ZIP 17//7 G <br /> PHONE#1EXT. APN# LAND USE APPLICATION# <br /> ( 0) (y �3 49)2-0 -o? <br /> PHONE#2 Z -Exr. BOS DISTRICT LOCATION DE <br /> (11/L 7 <br /> ONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EFT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 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 <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,ST and FEDERAL laws. <br /> APPLICANT'S SIGNATURE:?�iU/iV,- DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br /> If�APPLICANT 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 same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: FO c) J 10L.A AJ Cf4 E G(�—' PPy vED <br /> COMMENTS: ^©�� <br /> CU\ GO <br /> S ppNME�'(ME <br /> HP��UEpPP <br /> ACCEPTED BY: �� 1./E ( ��, EMPLOYEE#: 1032— DATE: s <br /> ASSIGNED TO: O k—'Lt M EMPLOYEE#: ! g DATE: S y <br /> Date Service Completed (if already completed): SERMCE CODE: S-�3 P 1 E: p <br /> Fee Amount: 3 S frt) Amount Paid 'A 5 Payment Date 511 2-(t O <br /> Payment Type Invoice# Check# O to ` Received By: Vrrr <br /> EHD 48-02-025 _ SR FORM(Golden Rod) <br /> REVISED 11/17/2003 C�— <br />