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SAN JOAQUI .OUNTY ENVIRONMENTAL REAL') DEPARTMENT <br /> SERVICE REQUEST <br /> XOWNER/:RAT <br /> ss or Property FACILITY ID# SERVICE REQUEST# <br /> S/UE�/T/f�L SPS CDC' 318 5 `S <br /> OPER CHECK if BILLING ADDRESS El <br /> FACILITY NAME h <br /> SITE ADDRESS /� STd����U/� /5 2 <br /> Street Number I Direction Street Name C" Zio Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> a 7 nr' AZ P/ Street Number Street Name <br /> CITY STATE ZIP <br /> STo CK o Al CA 9 5-2 LE <br /> PHONE#t APN# LAND USE APPLICATION# 4 v <br /> ( ) N P <br /> PHONE#2 FXT• BOS DISTRICT LOCATIoNCODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# <br /> HOME or MAILING ADDRESS FAX# <br /> F-- a- <br /> CITY STATE CA <br /> ZIP <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,S TE and FE laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> �/ <br /> PROPERTY I BUSINESS OWNER❑ OPERATO MANAGER ❑ OTHER AUTHORIZED AGENT L':J <br /> IfAnLicxw is not the BILLING PARTY,proof of a horization 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 envirorunental/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: NITAArE GOAD/ NT <br /> Coa1slENTs: f RECEIVED <br /> d/1-3/off 2004 <br /> �/ / -7/- _ JUN 11 <br /> M,/—' 6�; To 3 SAN JOAOUIN COUNTY <br /> Ov/tJrzl, Cg D!I?�"j� ENF h4 ENTAL <br /> FiFALTH 4-I DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: d <br /> ASSIGNED TO: �L , n EMPLOYEE#: �/ DATE: �7 <br /> Date Service Completed (cif already completed): SERVIICErCODE: P!E: 0 <br /> Fee AmoVnt: S Amount Paid ,(k Payment Date <br /> Payment Type ✓ Invoice# Check# 600 Received 13y. ��� <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11hW2003 <br />