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7x 1101, <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 4 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY LD# � � SERVICE REQUEST#� <br /> 'mmi 04PA� - <br /> OWNER IOPERATORW nn CHECKIfBIILINflA4�sus❑ <br /> M S , u <br /> FACILITY NAME <br /> SITE ADDRESSVpCada <br /> umber I DirectionstrelktNgme <br /> HOME Or MAILING ADDRESS (if Different,from Site Address) <br /> StreetNumber Sftest <br /> CITY STATE zip <br /> PHO(NEE##1 Exv APN# LAND USE APPLICATION# <br /> PHONE#2 Exr. $OS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR�f� M CHECK If BILLIBg ADDREBILL <br /> 1 BUSINESS NAME � � r� 4-*J6, •_SL �1 '�- . P NG �" 1 � <br /> C�G a L <br /> HOME or MAILING ADDRES O FAX# ) <br /> CITY !1�iecc& STATE /' ZIP <br /> PILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTI{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 applicati and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,,standards,STA FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE; 116P X�6 1]2 <br /> PRor ERTy/Busmss OXVNER❑ OPE MANAGE OTHER AUTHORIZED AGENT❑ <br /> IfAPPMCANTis not theJ?lLLwaPARTY 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:outh_arize.�the_relea e_of_any,and_al -resultsTgeotechnical data-and/or_-environmental/sitr-amessmnt <br /> information to the S,aN JO,Q6N COUNTY EANVIRoNMENTAL HLALTH DEPARTMENT as soon as itis available and at the same time it is <br /> provided to me or my representative. <br /> TYPE of SERVicE REQUESTED. 4 y yF <br /> COMMENTS: - I INFO sb <br /> C"..- Q s y <br /> J04oVfv <br /> ACCEPTED BY: L' �� EMPLOYEE#: DATE: <br /> ASSIGNED TO: O\ -e EMPLOYEE#: DATE: v.._ '"�_ !— <br /> a Date Service Completed (if already completed): SERVICE CODE: C)kC) PIE: <br /> Fee Amount: Amount Payment Date q <br /> Payment TypenL Invoice# Check# /0.Z7/;-) ` Ikerelved By- <br /> EHD 48-02.025 SR FORM(Golden Rod) <br /> REVISED 11/17t2003 " <br />