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SAN JOAQU �OUNTY ENVIRONMENTAL HEALTE. ;PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />COMMENTS: <br />FACILITY ID # <br />SERVICE REQUEST # <br />(:� p,S STATI"tJ <br />PHONE# <br />(4g <br />E'AULC <br />a43 - <br />STZ co s:- a-�s� <br />OWNER / OPERATOR <br />—J��1 - CHECK If BILLING ADDRESS <br />- <br />FACILITY NAME <br />CITY �C au- -30C a <br />SITE ADDRESS <br />ZIP Q SI <br />Payment Type <br />Invoice # <br />Check III <br />Received By: <br />Street Number <br />Di t nStreet <br />Name <br />HOME or MAILING ADDRESS (If Different from Site Address) t 8 <br />vrplle.L'�Lt$Q. I�lQJ1 np�. <br />Street Number <br />Simet Name <br />CITY -y� ('� <br />l <br />STATE �A ZIP <br />T U <br />PHONE #1 E", <br />197Si �ro'1 — X707 <br />APN # LAND USE APPLICATION # <br />PHONE #2 ENT. <br />I ) <br />BOS DISTRICT <br />LOCATON CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR We��AQ,h <br />COMMENTS: <br />CHECK If BILLING ADDRESS ® <br />BUSINESS NAME <br />,'q-a�S ,n- <br />DATE: <br />PHONE# <br />(4g <br />E'AULC <br />a43 - <br />HOME or MAILING ADDRESS- • <br />�D Ucwt't L <br />Date Service Completed (if already completed): <br />FAx <br />( �) <br />a(3- Do" <br />CITY �C au- -30C a <br />STATE t4 <br />ZIP Q SI <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 />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:U �)-iii eLc stt p tA� DATE: /Lsl(.1.10Oq <br />PROPERTY/BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT a L06L{.(�,�[(�((�.� &-fct� <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 />infomtation 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: w,tr�� i to _C -k4% <br />COMMENTS: <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I E: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check III <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/1712003 <br />