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s <br /> SAN JOAQUI OUNTY ENVIRONMENTAL HEALTI- 1PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ��G �SERVICE REQUEST#3� i milli <br /> OWNER/OPERATOR ^'p <br /> 1�.� I�� '��j �� CHECK If BILLING ADDRESS <br /> FACILITY NAME ARP � in ; NI ar-I- -� b <br /> SITE ADDRESS ]5-1-7 T S r pa}�.�.er sa n Pass Tracy �S�7,0v Street Number Direction Street Name Ci 2i Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 EXT" APN# LAND USE APPLICATION# <br /> PHONE#2 EXT" BIDS DISTRICTLOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I CHECK if BILLING ADDRESS <br /> �ar_n'�/Il <br /> BUSINESS NAME 4 r LV /� SEE o l.-EU/•l S E IL-art PON # EXT. <br /> HOME or MAILING ADDRESS /t 11 PE i P— FAx# S y <br /> Szj �f'Glb'1�1f1 '�r�n S7' : (gv9)Sq C7 <br /> CITY e)cc, f CLI STATE / T ZIP lo-'5-3 / <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 prepared this appli tion and that the work to be performed wil be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA and FEDE Laws. <br /> APPLICANT'S SIGNATURE: ,L i DATE: 3// 7 f 0K <br /> pp�� I— <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ya C�f/) (� ( d r <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-�is <br /> provided to me or my representative. <br /> TYPE OF SER CE REQUESTED: I(ket 0eelfr foef T(e5w(e-Ghe IP-ciK Deis U ToLML SQ Aos <br /> COMMENTS: R tfaa013-tP6te. gwsve+ Ian -P DPWbuc�1- on +Au q/ P-' P— <br /> 59 6►PhonTamV--, U REC N <br /> - tANit 1 b <br /> JOAQUIN COUNN <br /> ACCEPTED BY: EMPLOYEE#: 2 DAT9'NL 1ViUp NT <br /> ASSIGNED TO: EMPLOYEE#: y DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Z V Amount Paid �!� CD Paymen Date 3 g' <br /> Payment Type Invoice# Check# I Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />