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SAN JOAQUIN COUNTY ENVIRONMFNTAL HEALTH DEPARTMENT FILE(of <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST-# <br /> A I & <br /> OWNER/OPERATOR <br /> FACILITY NAME CHECK if BILLING ADDRESS <br /> SITE ADDRESS <br /> Sin Street Name Zip Cad <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> a SA I L4 1,,e&N..h., L <br /> CITY -T R-b*iz-y STATE C-A Zip <br /> PHONE#1 EXT, APN# LAND USE APPLICA*nON# <br /> (146& r7_I a'f <br /> PHONE#2 Ex'r. B05S DISTRICT LOCATION CODE <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESSE] <br /> BusINEss NAIF PHONE# Exr. <br /> (-Z ,�6) �-�� <br /> HOME or MAILING ADDRESS FAx# <br /> CITY STATE <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 ENvTRONMENTAL HEALTTi Dr-.PARTMEN'r hourly charges associated with this project 2'.A <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 ;AN JOAQUIN <br /> CouNi-Y Ordinance Codes,Standards,STATF�.and FEDERAI,laws. <br /> 01 <br /> APPLICANT'S SIGNATUR,E: DATE: <br /> -1 /M GER OTHER AUTHOWED ACENT <br /> PRoPEwry/BUSINESSOWNER11 RATOR ANA <br /> 'I t ,BILLL <br /> 1fAPPL1CAVTisnol e BILLLN,G PARTY,proofofautitorization to siqn is required Title <br /> AUT14ORIZATION 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 /> Z' <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HFALTH DEPARTMFNT 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: Ne4d <br /> COMMENTS: <br /> 7e- <br /> IY4 Y I I <br /> 84AIjo, <br /> lyjNV'!AQJJ//V <br /> /1. IONA,— <br /> TP At <br /> AcCEPTEr)BY: EMPLOYEE DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> 7- c2-i(-1-7 <br /> Date Service Completed (if already completed): SERVICE CODE' PIE: 1� <br /> Fee Amount: -/-\ Amount Paid 112- Payment Date -7 <br /> OIL) I <br /> PaymentType invoice# Check# 21 -7�, If Received By: 16, <br /> EHD 48-02-025 SIR FORM(Golden Rod) <br /> REVISED 1111712003 <br />