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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Buslness or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> FO�H r LU v P/M�TNt=7Z�S L-G-L <br /> FAciuTY NAME <br /> SITE ADDRESS 22 SD GLI-G'��4 CAI,-4 Al <br /> Street Numm <br /> ber Direction Street Nae Ci ZI Lode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICA�� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR r <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> �4c_vC3 H A NCC <br /> BUSINESS NAME PHONE# EzT. <br /> i�tLc.o�v Mc�2P '/ Zo`I 334—f-49bt3 <br /> HOME Or MAILING ADDRESS FAX# <br /> (w,l ) 3 3'-t - o 7 Z 3 . <br /> CITY STATE ZIP �5-- i <br /> L-UtTi <br /> BILLING ACKNOWLEDGEMENT: 1, 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 <br /> or 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,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: CO <br /> PROPERTY/BUSINESS OWNER❑ FRATOR/MANAGER ❑ OTHER AUTIIORIZED AGENT❑ <br /> !f APPLICANT 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 environmentaUsite 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: <br /> COMMENTS: VLC/.j j�.- ` ECEIVED <br /> OCT 6 ZOOS <br /> sAFNaARONMEN AL <br /> ACCEPTED BY: EMPLOYEE#: ATE: <br /> ASSIGNED TO: i 9 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): L'Cl SERVicECODE: I P I E: <br /> Fee Amount: -7 CA Amount Paid ] Payment Date <br /> Payment Type I Invoice# Check# ` ` Received By: Q\f4,-- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />