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t SAN JOAQUIN UNTY ENVIRONMENTAL HEALTH "EPARTMENT 64 L(_ <br /> SERVICE REQUEST 00cl — 40-2 — CLQ <br /> Type of Business or Pr it _ FACILITY ID# SERVICE REQUEST# <br /> Y1( 6224- <br /> 04 _ �Ci 2---757 00 SqR Zf <br /> OWNER/OPERATOR 1 DIM <br /> ��_, CHECK If BILLING ADDRESS <br /> FACILITY NAME ����) <br /> SITE ADDRESS ��C) , L f t--/ S-72- -iLU <br /> Street Number I Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Differ pnt from S' e Addres <br /> v Vatc!WStreet Number Street Name <br /> CITY STATE ZIP <br /> �&nhlyw U) 9452-to <br /> PH0NE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( s <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAMEi I �D �� l �� PHONE# EXT. <br /> 1� Z <br /> HOME AILING ADDRESS � � � FAx# <br /> 2 ( ) <br /> CITY C � ti <br /> BILLING ACKNOWLEDGEMENT: I, 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 or <br /> activity will be billed to me or my business s identified on this form. <br /> I also certify that I have prepared this ap i ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, E and FEDERAL laws. r <br /> APPLICANT'S SIGNATURE: DATE: ` <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is o 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 /> WL- <br /> TYPE OF SERVICE REQUESTED: CION �L,¢,J CY-{��,� — �-Erb-(p�aEL PAV[D <br /> COMMENTS: n 5. � ' 1 r <br /> /„N IUpCUIN COUNTY <br /> ENVI FiOIVMENTAL <br /> HEhLTH DEPARTMENT <br /> ACCEPTED BY: d Li v EMPLOYEE#: D3 Z, DATE: -5-11f h <br /> ASSIGNED TO: L D k C�i u7 EMPLOYEE#: 3 3(or DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S"'Z-Z PIE: <br /> Fee Amount: it 2-3v , ev Amount Paid 10 O Payment Date srtk�( <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />