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M SAN JOAQUIN )UNTY ENVIRONMENTAL HEALT EPARTMENT <br /> StRVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> y �'l�'s,.G��:s�'rK ��,t?rvrs eek,.,, G✓� 5 <br /> !) <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> ` FACILITY NAME <br /> SITE ADDRESS �-8 <br /> Street Number Directione'l Street Name Ci Zi Cade <br /> i <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE Zip <br /> PHONE#t EXT. APN# LAND US PL ATION# <br /> (d1)3a �- aa2.2 -(:)3 <br /> PHONE#Z EXT. BOS DISTRICT LOCATION ODE <br /> fs <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT• <br /> (O 'fid <br /> HOME or MAILING ADDRESS FAX# <br /> 1 CITY b STATE Zip <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDL la <br /> T <br /> APPLICANT'S SIGNATURE: 7�—�A, _ DATE: d`h <br /> PROPERTY I BUSINESS OWNER 0— PERATO /MANAGER ❑ OTHERAUTHORIZE'D AGENT❑ <br /> i <br /> If APPLICANT is not the BILLTNG 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 /> 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 /> k TYPE OF SERVICE A J <br /> COMMENTS'. "!� <br /> RECEIVED <br /> JAN 9 <br /> 2004 <br /> SAIq JOAQUIN COUNTY <br /> 3 Q� 1-:NViRONMENT ENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: .?� �. P!E: <br /> Fee Amount 1 Amount Paid6' r10 . Payment Date 1 Q� <br /> Payment Type Invoice# Check#` y), 6cei`ved By: kj <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />