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SAN JOAQUIN ' -)UNTY ENVIRONMENTAL HEALTF "EPARTMENT <br /> SERVICE REQUEST <br /> Type,Qf Busines or Property FACILITY ID# SERVICE REQUEST# <br /> ( i'n 'Wal <br /> IP4-60036/.5 <br /> OWNE /OPERATOR Lw I <br /> � CHECK If BILLING ADDRESS <br /> FACILITY NAME ( / ,\ „n n q <br /> SITE ADDRESS Y LU I16r <br /> 25 9� � �� p �� �a <br /> Street Number Direction Street Name i Zi Code <br /> HOME or M ILI A RES (If Different from S' I Adldr SS) ' <br /> I reet tuber Street Name <br /> CITY STATE ZIP <br /> od & 96 - : <br /> PHONE#"1 ExT. APN# LAND USE APPLICATION# <br /> ("tq ) r- 7 77 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( - -07 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEkadrtyy � PHONE 33 ExT. <br /> HOME Or MAILING ArDDRESS , , Ii n I FAX# ) <br /> CITY /� / STATE - -ZIP <br /> BILLING ACKNOWLE GEMENT:VI, 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,,ITATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �,lN l DATE: w� <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. 1,gYNjEN <br /> TYPE OF SERVICE REQUESTED: us T �T/,it�l /J� D <br /> PIARq <br /> COMMENTS: !i 2005 <br /> SAEJOAQUIN COUNTY <br /> RONki <br /> HEALTH b PAR MENT <br /> ACCEPTED BY: �,�I .� �1 EMPLOYEE#: 03al DATE: OJ 4.2eLr <br /> ASSIGNED TO: (/QA/ ��G`!l/ EMPLOYEE#: 8.3 r, DATE: D,3 p2 OS <br /> Date Service Completed (if already completed): SERVICE CODE: • %d P 1 E: 2308 <br /> Fee Amount: 4'o Amount Paid Payment Date,AIA F� <br /> Payment Type Invoice# Check# Received By: �J <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />