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I�N <br /> � SAN JOAQUIl` UNTY ENVIRONMENTAL HEALTiEPARTMENT <br />{ SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SSW -350- 39 <br /> F <br /> OWNER I OPERATOR <br /> CHECK If BELLING ADDRESSE] <br /> 1 FrQr) C C a gNa k <br /> it FAt71LF1Y NAME <br /> ,k <br /> ;k SITE ADDRESS T-- <br /> S <br /> Street Number DireSon �Q Street t Name + AQ C Ci Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> fI <br /> Sl so aF S r�ee* Street Number Street Name <br /> CITY ATE _ ZIP C�s 317 f <br /> c <br /> PHONE#1 APN 0 LAND USE APPLICATION# <br /> Bir 92 <br /> I } PHONE#2 ExT• BOS DISTRICT LOGATtON CODE <br /> r <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR l! C Q 12-10 G,�aM CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# E"T' <br /> Rt <br /> G. A 03s— -L <br /> I HOME or MAILING ADDRESS FAx# <br /> kk S7Sn ,�F.� gftLe�� ( .o ) 832- 0921 <br /> f CITY pSTATE �!� ZIP QS.3'O'1 <br /> [ <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> kacknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> �k activity will be billed to me or my business as identified on this form <br /> rI 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE:^ �,�� (f a, DATE: <br /> ! PROPERTY I BUSINESS OWNED OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLi ANT is not 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 /> iF 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. T <br /> f TYPE OF SERVICE REQUESTED: L/I RQ,/�C�1VE <br /> r COMM NTS: � 11'N 2004 <br /> � �y b o�. , (} `7� � <br /> /L'e� �y jOAQUIN cOUN'y <br /> �ENVIRRNMENT 1- <br /> Mon (-3 0 M1�14 <br /> ACCEPTED BY: EMPLOYEE#: DATE: a <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Ei Date Service bornpleted (if already completed): SERVICE CODE: sZ� PIE. <br /> Fee Amount: Amount Paid ( �S Payment Date b ytC <br /> Ll <br /> I Payment Type ✓ Involce# Check# Received By: <br /> EHD 48-02-025 7 / r SR FORM(Golden Rod) <br /> REVISED 11/17/2003 ,� <br />