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J SAN JOAQUI,.. 'OUNTY ENVIRONMENTAL IEALT'"'9EPARTMENT <br /> SERVICE REQUI,ST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OVYNER 1 OPERATO r CHECK if BILLING ADDRESS <br /> iJ <br /> f <br /> FAcIULY NAM <br /> r <br /> SITE ADDRESS n�Q� yim�., 1 <br /> �J Strelet Number'``D'ire�ctilon�( S rest Name Ci Zi(pCo`ddee <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#; 1T APN 0 /� TBOS <br /> AND USE APPLICATION#/� l' <br /> vD �--`�/ ^�,P <br /> PHONE#2 �• DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORCHE=CK if BILLING ADDRESS E] <br /> BUSINESS DAME/! •,_ l PHONE# r O E11r• <br /> HOME or MAILING ADPRESS FAX# f <br /> 04 <br /> CITY G� STATE ZIP y� <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 ENVLRoNMENTAL 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.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,,Sta TE and FEDERAL,laws. <br /> APPLICANT'S SIGNA DATE: _ <br /> PROPERTY/BVsmm OWNER❑ P Olt/MANAGER ❑ OTHER AvTHOR=D AGENT E ' <br /> 1fAPPL7c4NT is not the BILLrNGPARTY.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 JOAQUIIV COUNTY ENvLRONMENTAL 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: 1U r`]J2-A-i-E .�%. NCS 0 1 mac_c771�1 r <br /> COMMENTS' f-- S-7 <br /> 12- <br /> / Api005 �. <br /> UIN COUNTY } <br /> OAQ L <br /> d SAN,V1FiONM�NTA NT <br /> ACCEPTED BY: HSL MPLOYEE#: Q 3Zr DATE: '7 !�� 6 - <br /> ASSIGNED TO: li5i—g 44 A EMPLOYEE M q&"-(2 DATE: -7! Q� <br /> Date Service Completed (if already completed): SERVICE CODE: �� � PIE: O 2_ <br /> Fee Amount: Lf X097-rD Amount Paid TD bq-7, S-D Payment bate -Z ZI � <br /> - 5 <br /> Payment Type Invoice# Check# I ID Received By: <br /> r EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />