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fJ>i. r <br /> SAN JOAQUIN COUNTY LNVIRONII'IL".N'I'h:L HEALTH DEPARTMENT <br /> SERVICF� IJEST <br /> 3 Type of Business or Property FACILITY ID#. SERVICE REQUEST# <br /> 3238` <br /> OWNER/OPERATOR CnEcKIf BILLING ADDRESS❑ <br /> �11�lA/E g97 STATS <br /> FACIUTY NAME / .INT>E 5 c <br /> SITE ADDRESS <br /> I <br /> i <br /> Street Number Direction Street Name CR ZiCode <br /> j HOME Or MAILING ADDRESS (it Different from Site Address) B ATLS <br /> QStreet Number Street Name <br /> CITY STATE Zip , <br /> CA <br /> nV <br /> j PHONE#1 Exr. APN# LAND USE APPLICATION It <br /> 1 c ) 2 iF4a2 - <br /> 1 PHONE 12 EXT. BOS DISTmc-r LOCATION CODE <br /> ( <br /> CONTRACTOR! SERVICE REQUESTOR <br /> REQUESTOR D a N (:f /�� ^1� CHECK If BILLING ADDRESS <br /> BUSINESS NAME �J PHONE# EXT. <br /> C E— NE , � C_o IUL 161 o <br /> HOME or MAILING ADDRESS FAX# . <br /> 4o c ) -z <br /> CITYu L O STATE ZIP <br /> BILI,IING ACKNOWLEDGEMENT: I, the Undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/Or project specific ENVIRONMENTAL 14EALTH DrPARTMENT 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,STA d FFDERXJRW . <br /> APPLICANT'S SIGNATURE: DATE: 1-69 -623 <br /> L'ItOPL•'R'rY/BUSINMS OWNER❑ Ci'LRATOR/ ANACER ❑ OT1I AuTuoRIZFm AGENT <br /> If APPLICANT is not the BILLING PnxTY proof of autltoriZ tion 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 cnvironmentallsite 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:-61,eRFArs(�(gs /rt/�� Q/� / K <br /> COMMENTS: 'h <br /> PAYMENT <br /> 0,40 <br /> , RECEIVED- s [ d JAN 10 2003 <br /> APPROVED DY: f EMPLOYEE#: G�j EN PU LSA-6AUX S Aff S <br /> ASSIGNED TO: EMPLOYEE#: (.� DATE: <br /> Date Service Completed (if already completed): SEFMCECODE: 1 P l E� <br /> Fee Amount: C ' � — Amount Paid T Payment Date ! /O/D 3 <br /> Payment Type ✓ Invoice# Check#f� Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> !!! REVISEO 6-5-02 <br />