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SAN 30AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID,# SERVICE REQUEST# <br /> ice n wk, 5�1� ►40 �557 �Mqqra <br /> OWNER/OPERATOR <br /> 7-ck c ,�.-tn � 'tl �� ��� CHECK If BILLING ADDRESS <br /> FACILnY NAME C /-Y% <br /> SrrEAnoREs/s� �8 �0� jrac <br /> GStreet Number LNrecdon Street Name C' L Code <br /> HOMEMAILING ADDRESS (if Different from Site Address) l e <br /> Street Number Name 1 <br /> Cm QCSTATE / ZIP <br /> PHONE#1`> Exr. APN# LAND USE (APPLICATION# <br /> PHONE#2 Em. BOS DISTmICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ,t <br /> /-t� CHECK If BIWNG ADDRESS <br /> BUSINESS NAME 1 Il (/\ PFI�NE# ExT <br /> HOME or MAILING ADDRESS ' _ ^J Ax# I <br /> CITY C I STATE 71P <br /> BILLING AC 'OWLEDGEINIENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and%or project specific ENVIRONMENrAI.HEALTIi 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 1 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 FFDFRAI,.laws. 9 <br /> APPLICANT'S SIGNATURE: DATE: `j�. � ! • <br /> PROPERTY/BUSINESS OWNER[ OPER,ITOR/i%L%,NAGER OTHER At:THORIZED AGENT❑ <br /> If APPLICA N7 is not the BILLIYG PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable.L the owner or operator of the property located at the <br /> above site address, herebv authorize the release of anv and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONktINTAT.HEALTH DEPARTNILNT as soon as it is available and atme time it is <br /> provided to me or my representative. c <br /> TYPE OF SERVICE REQUESTED: C <br /> CO11 ENTS: <br /> %A Q 9 2419 <br /> q <br /> N � Uq RCO�hry <br /> Rt,yRH <br /> ACCEPTED BY: EMPLOYEE#: L DATE: / 1 <br /> ASSIGNED TO: EMPLOYEE#: [ DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: d P I E: O <br /> Fee Amount: / .SZ Amount Paid �,5,�_�� Payment D/ate !� <br /> Payment Type s Invoice# Check# _7Z t#%13 Recelv By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />