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SAN JOAQ1. COUNTY ENVIRONMENTAL HEALT, EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> LzRS S�Ai�4t� Sss z'- goO7v <br /> OWNER/OPERATOR <br /> �t°Sov-O CHECK If BILLING ADDRESS <br /> FACILITY NAME 1\l �1' <br /> SITE ADDRESS�V+l <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. N# LAND USE APPLICATION# <br /> (:�L4)jAP <br /> ) o / <br /> PHONE#Z EXT. BOS DISTRICTCATION CODE <br /> _ F <br /> caC�9> 3-i34- b��� �L- <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> �Y" � L1i CHECK If BILLING ADDRESS® <br /> fy <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAx# <br /> 61' b v LL&u1 e, HO > &0-* <br /> CITY <' Q A `` STATE /:n ZIP Q�I <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, ope`r`a'ttor 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �. (.� �= L�r,. � C 'i lc�Gi 6 DATE: x/01I'ZI`t1 y. <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT �UI✓L��.tC�(!� t � i`-Qr <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. <br /> TYPE OF SERVICE REQUESTED: G( S�T L -1-� t / <br /> COMMENTS: I IIVSpt6CC A -f W (&L V1StCLU-&* C m er ao� cst.I ksw' T <br /> �juS�C-e� <br /> RECEIVED <br /> 3 0 007 <br /> ACCEPTED BY: t t V/ C ( UL <br /> EMPLOYEE#: �� ZQ DATE: � �I� ME �, <br /> ASSIGNED TO: V C:of F Lu-F— EMPLOYEE#: Ii-317 0 07 <br /> DATE: HF <br /> Date Service Completed (if already completed): SERVICE CODE: 199 P It: 8' <br /> Fee Amount: 3 S, Lt� Amount Paid g S CSD Payment Date S-R -7 <br /> Payment Type Invoice# Check# ��.J�- Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />