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' SAN JOAQUIPLCOUNTY ENVIRONMENTAL HEALT EPARTMENT <br /> } SERVICE REQUEST - <br /> Type of Business or Property FACILITY iB# ' SERE REQUEST <br /> k5s oFArri,4L Ao-.Fe'61 <br /> nG <br /> OWNER l OPERATOR <br /> 'I �� Al <br /> �� CIA CHECK If BILLING ADDRESS❑ <br /> FA Lay DAME J� <br /> SITE ADDRESS i �(Erg (G� I/V0 05,A/ <br /> V Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Sit leff Address) <br /> II. Street Number Street Name <br /> CITY STATE Zip <br /> M <br /> PHONE#1EXT' APN# LAND USE APPLICATION# <br /> ( )14 o t o s'oo f o .--azo -as <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR[SERVICE REQUESTOR <br /> REQUESTOR J.� CNECK1fBILLINGADDRESS <br /> BUSINESS NAME /V PRONE# EXT. <br /> C r—lRIE Gc L �/ 66 ?- o <br /> HOME or MAILING ADDRESS 1. FAX# <br /> CITY /amu 1Z 6V C-� I� STATE ZIP 3 <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 tapponand thaa work to be performed will be done in accordance with all SAN JOAQUN <br /> COUNTY Ordinance Codes,StandardsD <br /> APPLICANT'S SIGNATURE: DATE: <br /> I �� <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ ER AUTHORizED AGENT <br /> 1fAPPL1CANT is not theBILLINGPARTY proof of autho tzation 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 therelease of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JoAQum COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. 'I1 <br /> TYPE OF SERVICE REQUESTED: of 7 <br /> COMMENTS: (p iSly� / Gj,� `PAX IvIm"iT <br /> �a3 <br /> ��r RECEIVED <br /> 1 MAY 2 <br /> ` SA�rivo+aoNM>=NSALTM <br /> Y <br /> ! ACCEPTED BY: I EMPLOYEEIAA <br /> J <br /> ASSIGNED TO: G' EMPLOYEE DATE:..gel e*� <br /> Date Service Completed (if already co Ieted : SERVICE Co 7_ P!E: . Qf <br /> Fee Amount: `� Amount Paid 037, JD Payment Date <br /> Payment Type Invoice#II Check# X319' Received By: <br /> Rod) <br /> ld <br /> FORM(Golden o <br /> EHD 48-02-025 SR � ) <br /> REVISED 11/17/2003 <br />