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IV RECEIVED <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> AN <br /> b <br /> SERVICE REQUESTINV�R(1 r <br /> rTy4pefusiness or Properly FACILITY 1D# SERVICE REQ13EBtR / EALTH <br /> SERV/ ES <br /> ,vSR CO�-7 0'7 <br /> OPERA II <br /> ,,,�. S /J CHECK ifBILUNGADDRESSO <br /> FACILITY NAME <br /> SITE ADDRESS <br /> St IV <br /> Street Number Direction Street Name <br /> HOME or MAILING ADDRESS (If Different from Site Address) c� zi coae <br /> Street Number Street Name <br /> f CITY <br /> 3 STATE ZIP <br /> P NE#1 E)cr. � <br /> APN# LAND USE APPLICATION# <br /> J— RAY <br /> PHONE#2 Exr• BOS DISTRICT LOCA-ndN o E <br /> ( ) �R <br /> CONTRACTOR / SERVICE REQUESTOR cAQUrN Co <br /> RE ESTO <br /> Ir '� CHECK If BILLING ADDRESS T 4kr <br /> BUSINESS NAME J7 CCCJJJ 66L P E <br /> Hoene or MAILING ADDRESS FAX# <br /> CITY <br /> STATE zip <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, FATE and FEDERAL,laws. <br /> APPLICANT'S SIGNATURE: <br /> DATE' <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR 41ANAGER ❑ OTHERAuT130RTZED AGENT <br /> IfAPPLICANT is not the Binf1VG 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. F <br /> TYPE OF SERVICE REQUESTED: rf Ie, <br /> COMMENTS: vvL <br /> �- lzo �. <br /> ACCEPTED BY: EMPLOYEE#: DATE: 1. <br /> ASSIGNED TO: I EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): I' SERVICE CODE: P 1 E: O 1 <br /> Fee Amount: �p Amount PO 17 UD Payment Date3v d7 <br /> Payment Type Invoice# Check* 7367a Received By: <br /> EFID 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br /> ,3 <br />