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SAN JOAQUI ;OUNTY ENVIRONMENTAL HEAL" -APARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0 _t C<A- 5 r&OD37 F6 <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS 6R 4IST L=N- RI) l 2A e q S3 7 <br /> Street Number Direction Street Name ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) -Se MT- Z� ` N C,t rZ <br /> eoW Street Number Street Namet �J <br /> CITY _T_n I T K4 STATET-� ' ZIP <br /> PHONE#I K V APN# LAND USE APPLICATION# t0 <br /> (q 12-) A(nq 13 C0 SL I-�Ck <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ,qC-Q) T59 5L014 <br /> 11 <br /> }� CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR i /�/N�� <br /> ' ) � CHECK If BILLING ADDRESS <br />/ BUSINESS NAME PHONE# EXT. <br /> (fwAELs (2Ts $ CL9 t=-rs <br /> HOME Or MAILING ADDRESSFAX# <br /> , IUT _J(2_kNCN4 -DiL ( ) <br /> CITY n U i�� STATET ZIP 44150 <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 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, TATE and FEDERAL laws. a <br /> APPLICANT'S SIGNATURE: `��%�� ���GD DATE: ✓/�� <br /> PROPERTY/BUSINESS OWNER❑ OPERATORANAGER OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PAR ,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 tlle.tame time it is <br /> provided to me or my representative. PA( STT ii <br /> TYPE OF SERVICE REQUESTED: Poco F-A C t L t r LA,j c F-C <br /> COMMENTS: M <br /> SANQUIN COUNV <br /> NV RONMENTAL <br /> `t�T►-I DEPhRtiWIECd�T <br /> ACCEPTED BY: O L ( EMPLOYEE M ( 2j 2-1 DATE: S ;� G <br /> ASSIGNED TO: FL`t`{ 2 SC,4U T-2— EMPLOYEE M 33(, /- DATE: <br /> Date Service Completed (if al-ready completed): SERVICE CODE: Z-� P 1 E: <br /> Fee AmoVnt: O C) Amount Paid �.C�3 b p Payment Date 5-[3 D Ll <br /> Payment Type Invoice# Check# 3 y Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />