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SAN JOAQUl ,OUNTY ENVIRONMENTAL HEALTI-,PARTMENT <br /> SERVICE REQUEST <br /> Type roBusiness or Pro a CILITY ID# SERVICE REQUEST# <br /> s [--� <br /> �� Sr2°D � 3yk <br /> OWNER OPERATQR CHECK If BILLING ADDRESS <br /> " I ►,; 4 rC <br /> EANAE `,,� <br /> S_ �I. , 1 + . -� Street Number D:---':-- reet N me CityZi de <br /> HOME Or MAILING ADDRESS (If Different from Site Address) . <br /> 3 s L A- Street Number N <br /> CITY � STATE ZIP <br /> . / / _ <br /> � � L A-)0 °V .f <br /> PHONE#1 <br /> Ezr. APN# LAND USE APPLICATION# <br /> $HONE,#2 Exr' BOIS DISTRICTLOCATION CODE <br /> ) 6(,8 4?cI <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOF A-m ,LIF-.�- �t AJ <br /> CHECK If BILLINGADDRESS© - <br /> PHONE#/ (x� fir' <br /> BUSINESS NAME. -� Y112 tiL, 4 C _� — :?. 1 <br /> 1 9/ `, <br /> HOME Or MAILING ADDRESSFAX# <br /> 3k& ! �- 4 C& W/3 Bio) 69 <br /> CITY 12& 14110 JU STATE C /�- ZIP L/ 3 <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 pre" <br /> a this application a that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes tandards, STATE EDERAL laws. <br /> APPLICANT'S SIGNATU DATE.j -7 )2 y t <br /> PROPERTY/BUSINESS OWNER❑ OPE OR/MANAGER ❑ OIHERAUTHORIZEDAGENV)L P.SIeA,*l'P�y <br /> If APPLICANT not the BiL PARTY proof of authorization to sign is/equ[Ted ` itle <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. /J ,/'' <br /> TYPE OF SERVICE REQUESTED: �O (� C-A ---) C f-I E G� — F EA,(OO—(— <br /> COMMENTS: Q-CerliejEO <br /> "300,0UN20�TM <br /> 9N�F-W-T)PPF-CiL �AEKI <br /> ACCEPTED BY: Q(�C J [ EMPLOYEE#: DATE: 2t& [L <br /> ASSIGNED TO: /i t SS t EMPLOYEE#: DATE: .Z t 2— <br /> Date <br /> Date Service Completed (if already completed): SERVICE CODE: 3 P":: 1 <br /> Fee Amount: 3'7,! J-[' Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />