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SAN JOAQUINCOUNTYLtNVIRONMEN [At, nr.AI,rn Lrr .w. •_�.• <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# r SERVICE REQUEST# <br /> Sk <br /> OWNER/OPERATOR CHECK If BILLING ADDR/ <br /> 'LE'S'S❑ <br /> FACILITY NAME 2-24 Ls,1 / t4. / (� 'A/�/ <br /> SITE ADDRESS 3 (. I�'l.. �'e'e Tftgc( C41 IJs <br /> -T5 <br /> Street Number Diet rection I StrelName Ci / ZiCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> )� (� O Lia Street Number Street Name <br /> CITYpn STATE <br /> ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> Illy <br /> PHONE#2 EXT, BOS DISTRICT LOCATION CODE <br /> > 8� L 11 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR �.^ 0 �/�D CHECK if BILLING ADDRESS <br /> BUSINESS NAME L n _ (��� BPir 4'n PNONE# E.T. <br /> il 831 d�6 <br /> FAX# <br /> HOME Or MAILING ADDRESS <br /> 23 ! Aa,GJ r Otil , > <br /> CITY 0 / 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. <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, TATE and FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: e � _ DATE: O <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER ❑ OTBERAUT}IORIZED 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. ENT <br /> TYPE OF SERVICE REQUESTED: RECE <br /> COMMENTS: C Ls 2L DST 12 200 <br /> yLOr.�y.Q w r S�NV RONIM EDIT <br /> Vf/y _ HATH pEPARTM <br /> ACCEPTED BY: OYEE#: DATE: <br /> ASSIGNED TOv'' EMPLOYEE#: <br /> Date Service Co eted (if already mple ed): SERVICE CODE: 0 (, ,/ pit: <br /> r <br /> Fee Amount: Amount Paid OU Payment Date /C 2 O <br /> Payment Type C{.{.ELInvoice# Check# Received y: l (� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />